>< 


^    : OONATCD 


. 


[Principles  and  Practice  of 
Infant  Feeding^ 


. 

JULIUS  H.  HESS,  M.D. 

Professor  and   Head  of  the   Department  of  Pediatrics,  University  of 

Illinois  College  of  Medicine;  Chief  of  Pediatric  Staff,  Cook  County 

Hospital;    Attending    Pediatrician     to     Cook    county,    Michael 

Reese   and  Englewood  Hospitals;   Consulting  Pediatrician, 

Municipal   Contagious   Hospital,   Chicago,  Etc. 


ILLUSTRATED 


THIRD  REVISED  AND  ENLARGED  EDITION 


PHILADELPHIA 

F.  A.  DAVIS  COMPANY,  PUBLISHERS 

1922 


COPYRIGHT,  1918 
COPYRIGHT,  1919 
COPYRIGHT,  1922 

BY 
F.  A.  DAVIS  COMPANY 


Copyright,  Great  Britain.     All  Rights  Reserved. 


PRINTED  IN   U.  S.  A. 

PRESS  OF 
F.     A.     DAVIS    COMPANY 


TO 

ISAAC  A.   ABT,   M.D. 

MY  FRIEND  AND  TEACHER 
THIS   BOOK    IS   AFFECTIONATELY   DEDICATED 


PREFACE  TO  THIRD  EDITION. 


IN  the  preparation  of  the  third  edition  the  chapters  on 
Vomiting,  Colic  and  Flatulence,  Constipation,  and  Ab- 
normal Stools  have  been  completely  rewritten. 

The  classification,  nomenclature  and  pathogenesis  of 
the  nutritional  disturbances  have  been  revised  to  conform 
to  the  latest  researches.  American  clinics  are  to  be 
credited  with  the  greater  part  of  this  progress. 

New  chapters  dealing  with  rickets,  scurvy,  spasmo- 
philia,  acidosis  and  anemias  of  infancy  have  been  added. 

JULIUS  H.  HESS. 

Chicago,  Illinois. 


(v) 


PREFACE. 


IT  has  been  our  experience  that  the  best  results  ob- 
tained in  the  teaching  of  the  principles  and  practice  of 
infant  feeding  have  been  accomplished  when  the  theory 
of  feeding  and  the  study  of  actual  cases  have  been 
combined. 

Our  object  in  publishing  this  volume  is  to  place  in 
the  hands  of  teachers  and  students  a  manual  on  infant 
feeding  to  be  used  in  preparation  for  clinical  confer- 
ences. Whenever  possible,  the  subject  under  discussion 
is  illustrated  in  the  class-room  by  clinical  cases  and  case 
records  from  the  teacher's  personal  material. 

While  there  are  many  excellent  works  covering  this 
subject,  we  have  found  most  of  them  to  be  too  volum- 
inous to  fulfill  our  needs,  and  we  have  therefore  at- 
tempted to  present  the  subject  in  concise  form  in  this 
small  volume. 

For  the  teaching  of  nurses  we  have  selected  those  chap- 
ters which  have  to  do  with  the  nursing  care  of  premature, 
healthy,  and  sick  infants,  the  feeding  of  breast-fed  and 
artifically  fed  healthy  babies,  and  the  preparation  of  in- 
fants' foods  and  diets. 

JULIUS  H.  HESS. 

Chicago,  Illinois. 


(vii) 


CONTENTS. 


PART  I. 

GENERAL    CONSIDERATIONS. 

CHAPTER  PAGE 

I. — Anatomy  of  the  Digestive  Tract  of  the  Infant  1 

II. — Physiology  of  the  Digestive  Tract  of  the  Infant 3 

III. — Metabolism  in  Infants 6 

IV. — Bacteria  of  the  Digestive  Tract  of  the  Infant   27 

PART  II. 

THE    NURSING. 

I. — General    Considerations    35 

II. — Maternal   Nursing    38 

III. — Wet-nursing 46 

IV.— The  Xursing  Infant   61 

V. — Mixed  Feeding  and  Weaning 63 

VI. — Nutritional  Disturbances  in  the  Breast-fed  Infant 67 

VII. — Methods  of  Feeding  Premature  Infants 84 

PART  III. 

ARTIFICIAL  FEEDING. 

I. — Recent  Progress  in  Artificial  Feeding  100 

II.— Cow's  Milk   103 

III. — Adaptation  of  Milk  for  Infant  Feeding  115 

IV. — Milk  Dilutions  with  Addition  of  Carbohydrates    119 

V. — Cream  and  Skimmed  Milk  Mixtures    155 

VI. — Feeding  in  Late  Infancy  and  Early  Childhood  158 

PART  IV. 

NUTRITIONAL   DISTURBANCES    IN    ARTIFICIALLY 
FED    INFANTS. 

I. — Minor    Disturbances    162 

II. — General  Consideration  of  Nutritional  Disturbances 187 

III. — Nutritional  Disturbances  Unassociated  with  Diarrhea  ..  200 

(ix) 


X  CONTENTS. 

CHAPTER  PAGE 

IV. — Nutritional  Disturbances  Characterized  by  Diarrhea  . .  218 

V. — Athrepsia   (Decomposition)    237 

VI. — Anhydremia  (Anhydremic  Intoxication)    259 

VII. — Infection  and  Nutrition  276 

PART  V. 
Rickets  (Rachitis)   304 

PART  VI. 
Spasmophilia   341 

PART  VII. 
Scurvy    358 

PART  VIII. 
Acidosis 384 

PART  IX. 
Anemias  of  Infancy    405 

Appendix    425 

Index  .  .  485 


ILLUSTRATIONS. 


FIG.  PAGE 

1. — Proper  method  of  holding  baby  during  nursing 57 

2. — Author's  improved  breast-milk  collector   58 

3. — Direct  expression  of  breast-milk,  Act  1    59 

4. — Direct  expression  of  breast-milk,  Act  2  60 

5. — Breck   feeder  for  premature  infants   87 

6. — Apparatus  for  gavage  and  lavage  88 

7. — Feeding  baby  with  catheter    89 

8. — Scale   for   weighing  infants    121 

9.— Infant  with  athrepsia   237 

10. — Chart  of  infant  with  athrepsia   245 

11. — Chart  of  infant  with  parenteral  infection   283 

12.— First  stage  of  rickets  322 

13.— Rickets  after  28  days  treatment    323 

14. — Rickets  after  43  days  treatment   324 

15. — Rickets,  extreme  degree 326 

16. — Enlarged  megalocolon  and  sigmoid  in  rickets 327 

17. — Extreme  changes  in  rickets   328 

18. — Spasmophilia   350 

19. — Spasmophilia    352 

20. — Spasmophilia,  Trousseau's  sign    353 

21. — Spasmophilia,  fractures  of  radius  and  ulna  356 

22. — Scurvy  in  guinea  pig  363 

23.— Scurvy— "White  Line"  of  Fraenkel  368 

24. — Scurvy  with  hemorrhage  into  knee  joints   369 

25. — Scurvy  with  hemorrhage  about  tibia  and  fibula  371 

26. — Scurvy.    Typical  lesions  of  the  gums  (colored)    . .  facing  372 

27. — Scurvy,  bilateral  proptosis    375 

28. — Utensils  used  in  artificial  feeding  445 

29. — Nursing  bottles    448 

30.— Milk   station , 449 

31. — Hospital  bathroom    452 

32— Hess  bed  462 

33. — Diagram  of  Hess  bed   463 

34. — Receptacle  for  heating  pads  (electric)   464 

Case  records   471  to  484 


(xi) 


LIST  OF  TABLES. 


PAGE 

Classes  of  food-stuffs  20 

Weight  gain  121 

Percentage  of  different  salts  in  human  and  cow's  milk 133 

Caloric  requirements  for  the  artificially  fed  infant  136 

Caloric  values  of  various  foods  138,  146 

Data  as  to  foods  and  food  requirements  139 

Food  elements  required  per  pound,  body  weight   140 

Equivalent  weights  and  measures  of  carbohydrates  143 

Elements  in  milk  mixtures   147 

Formula  for   feeding    148 

Proper  ingredients  for  child  of  8  months   150 

Diet  for  new-born  infants  during  first  four  weeks  151 

Condensed  milk  content    429 

Average  weights    466 

Measurements    467 

Eruption  of  deciduous  teeth    468 

Eruption  of  permanent  teeth    468 

Average  daily  quantity  of  urine  in  health    469 

Average  rate  of  pulse  and  respiration   469 


(xiii) 


INTRODUCTION. 


THE  dependence  of  the  offspring  upon  its  mother  for 
food  to  supply  its  primitive  needs  can  only  be  realized 
when  we  remember  that  one-fourth  of  the  civilized  race 
die  during  the  first  year  of  life,  and  that  60  per  cent,  of 
these  deaths  are  due  to  nutritional  disturbances,  while  a 
large  portion  of  the  other  40  per  cent,  are  primarily  de- 
pendent upon  impairment  of  the  infant's  constitution  by 
improper  feeding.  The  mortality  of  the  first  year  is 
nearly  60  times  that  of  the  fifteenth  year,  and  it  is  not 
until  we  approach  the  85th  year  that  we  meet  with  such 
a  high  percentage  death-rate.  The  problem  is  not  simply 
to  save  life  during  the  perilous  first  year  but  to  adopt 
those  means  which  shall  tend  to  healthy  growth  and  nor- 
mal development.  The  child  must  be  fed  not  only  to 
avoid  the  immediate  dangers  of  acute  indigestion,  diar- 
rhea, and  marasmus,  but  the  more  remote  ones — rickets, 
scurvy,  and  general  malnutrition.  These  latter  three  are 
the  most  important  conditions  that  predispose  to  disease 
in  early  life. 

A  growing  child  requires  far  more  food  than  its 
weight  would  indicate.  For,  in  the  first  place,  its  intake 
must  exceed  its  expenditure,  so  that  it  may  grow.  The 
expenditure  of  an  organism  is  pretty  nearly  in  propor- 
tion, not  to  its  mass,  but  to  its  surface.  The  skin  surface 
of  a  boy  from  6  to  9  years,  with  a  body  weight  of  18  to 
24  kilograms  (40  to  50  pounds),  is  two-fifths  to  one-half 
that  of  a  man  of  70  kilograms  (154  pounds),  and  he 

(xv) 


xvi  INTRODUCTION. 

should  therefore  have  about  half  as  much  food  as  the 
man.  This  disproportion  in  the  needs  of  the  infant  as 
compared  with  the  adult,  is  even  greater  than  that  of  the 
child  compared  with  the  adult.  By  exact  measurements 
it  has  been  determined  that  an  infant  from  its  fourth  to 
the  sixth  month  consumes  about  twice  as  much  food  per 
kilogram  body  weight  as  the  adult. 


PART  I. 
General  Considerations. 


CHAPTER    I. 

THE    ANATOMY    OF    THE    DIGESTIVE    TRACT 
OF    THE    INFANT. 

Oral  Cavity.  The  salivary  glands  are  well  developed 
at  birth,  and  the  active  principles  of  the  salivary  secre- 
tion are  present,  but  in  small  quantities.  Teething  begins 
at  about  the  sixth  month,  and  dentition  is  not  completed 
until  about  the  end  of  the  second  year.  In  most  instances 
this  is  a  normal  physiological  process,  and  should  cause 
no  disturbances.  However,  in  a  considerable  number  of 
cases  the  gastric  and  intestinal  secretions  are  affected  re- 
flexly,  with  a  diminished  activity  on  the  part  of  these 
glands ;  and  if  there  is  any  tendency  to  a  general  disturb- 
ance during  this  period,  a  reduction  in  the  quantity  of  the 
food  administered  is  indicated.  However,  far  too  great 
an  importance  is  usually  given  by  the  laity  to  the  process 
of  teething. 

Stomach.     In  the  newborn  the  stomach  has  a  more 
vertical  position  than  in  the  adult.     However,  rontgen- 
ologic examination  has  demonstrated  that  it  is  less  ver- 
tical than  has  been  formerly  supposed.    The  cardiac  end 
is  found  at  the  left  of  the  tenth  dorsal  vertebra.     The 
pylorus  lies  about  midway  between  the  ensiform  cartilage 
and  the  umbilicus.    The  position  of  the  stomach  and  its 
form,  due  to  lack  of  development  of  the  fundus  and  lack 
'  I  of  muscular  development  at  the  cardiac  end,  account  in 
I  great  part  for  the  frequency  of  vomiting  in  the  infant. 

The  pylorus  also  lacks  the  muscular  development  of 
the  adult,  and  is  decidedly  more  patent. 

(1) 


2  INFANT   FEEDING. 

Considerable  difficulty  is  experienced  in  our  attempts 
to  gain  accurate  knowledge  of  the  capacity  of  the  stom- 
ach. Pfaundler,  who  measured  the  size  of  the  stomach 
in  numerous  infants,  using  air  under  a  given  pressure,  has 
given  us  figures  which  are,  in  all  probability,  fairly  ac- 
curate. 

He  states  that  the  capacity  at  birth  is  2  ounces  (60 
mils),  at  one  month  2  to  3  ounces  (60  to  90  mils),  at  six 
months  6  ounces  (180  mils),  and  at  one  year  9  to  10 
ounces  (270  to  300  mils).  The  importance  of  the  stom- 
ach's capacity  in  determining  the  size  of  the  individual 
feeding  is  only  relative,  dependent  to  a  great  extent  upon 
the  form  of  diet.  With  milk  as  the  food,  a  considerable 
portion  of  the  water  content  passes  through  the  pylorus 
before  the  meal  is  finished,  if  the  food  is  not  too  rapidly 
given.  When  a  child  is  fed  by  gavage,  the  size  of  the 
meal  is  of  greater  importance  because  of  the  danger  of 
overdistention  by  the  rapid  administration  of  the  food  by 
this  method.  Notwithstanding  the  fact  that  the  size  of 
the  stomach  varies  in  different  babies,  we  have  found  it  a 
good  working  rule  with  normal  infants  to  administer  at 
leach  feeding  a  quantity  2  ounces  more  of  the  liquid  food 
(than  the  infant  is  months  old. 

The  intestines  are  relatively  larger  than  in  the  adult, 
(  which  applies  more  especially  to  the  large  intestine,  and 
/  particularly  to  the  sigmojo^  flexure.  The  sigmoid  is  also 
more  mobile,  due  to  the  greater  length  of  the  mesosig- 
moid,  and  is  extra-pelvic.  The  musculature  is  rela- 
tively thin,  and  bears  an  important  relationship  to  the 
frequency  of  intestinal  distention  and  the  presence  of  colic, 
which  is  due  to  the  stagnation  of  large  quantities  of  gas 
in  the  intestinal  tract. 

The  pancreas  shows  no  special  anatomical  differences. 

The  liver  is  relatively  two-and-a-half  times  as  large 
at  birth  as  in  the  adult,  and  is  easily  palpable,  and  in  the 
nipple-line  of  the  right  side  usually  extends  1  to  \l/2 
inches  (2  to  4  cm.)  below  the  costal  border. 


CHAPTER    II. 

THE    PHYSIOLOGY    OF   THE*  DIGESTIVE 
TRACT    OF   THE    INFANT. 

WHILE  all  the  ferments  are  present  in  early  life,  they 
vary  quantitatively  and  qualitatively  as  compared  with 
older  children. 

Mouth.  Ptyalin,  which  is  an  amylolytic  ferment,  is 
present  in  the  saliva  immediately  after  birth,  but  is  small 
in  amount,  and  weak  in  its  action.  Albumin,  water  and 
mucus  in  saliva  vary  with  the  variety  of  food  taken 
(Pavlow). 

Stomach.  Gastric  juice  is  present  in  the  stomach 
even  in  the  premature.  Its  secretion  is  mainly  stimu- 
lated by  the  act  of  sucking  and  by  the  presence  of  the 
food  in  the  stomach. 

Freq  hydrochloric  acid  is  little  less  than  in  the  adult. 
It  may  be  stated  that  the  small  protein  content  of  human 
milk,  as  compared  with  cow's  milk,  favors  the  presence 
of  hydrochloric  acid.  This  is  a  point  of  great  importance 
in  the  food  problem  of  the  infant.  Free  hydrochloric 
acid  is  iQnnd  in  10  per  cent,  of  cases  after  1  hour,  and  in 
33  per  cent  of  cases  after  l*/2  hours  on_  feeding  with 
human  milk  (Hamburger  and  Sperck).  With  cow's 
milk,  fr^e  Hvrlr^klr.t-iV  i^'d  is  found  very  rarely,  which 
is  due  to  rnmbinatinn  of  the  hydrochloric  acid  with  salts 
and  proteins.  Total  acidity  is  in  small  part  only  due  to 
free  hydrochloric  acid.  More  important  are  phosphoric 
acid,  acid  phosphates,  acid  chlorides,  fatty  acids  and  acid 
alp~u"mrns  (albumqse£_and  peptones').  Total  acidity  is  20 
to  60  mils  N  :10  acid  to  100  mils  of  gastric  contents.  The 

i action  of  the  hydrochloric  acid   is  as   follows:    (1)    it 
makes  protein  digestion  possible   (acid  albumins)  ;   (2) 

(3) 


4  INFANT   FEEDING. 

stimulates  ^he  pancreas ;  (3)  disinfects  and  exerts  anti- 
toxic Action. 

The  following  ferments  are  present  in  the  stomach : 
( 1  }  Pepsin,  which  is  present  at  birth,  and  is  active  and 
CSmseji  at  least  partial  digestion  of  proteins.  It  increases 
tojhe  fourth  month,  then  remains  fairly  constant.  More 
pepsin  is  present  in  bottle-fed  infants.  (2)  Rennin  is 
also  present  at  birth,  and£h  ihe  presence"of  hydrochloric 
acid  coagulatesjTiilk.  Whether  this  is  dependent  on  pep-  l\ 
*)[  sin.,  or  whether^it  is  a  specific  ferment,  is  a  question.  '  » 
(3)  Lipase,  a  fat-splitting  ferment,  is  found  in  the  stom- 
ach in  small  quantities,  and  is  probably  a  definite  product 
of  the  gastric  mucosa. 

Small  Intestines.  Mucous  membrane  of  the  small 
intestines  secretes  about  1  liter  of  juice  daily,  and  this 
contains  all  ferments  at  birth,  they  being,  however,  rela- 
tively feeble  at  first.  The  following  ferments  are  pres- 
ent in  the  intestinal  secretion:  (1)  erepsin  (Cohnheim), 
which  splits  casein,  albumoses,  and  peptones  to  peptids 
and  amino-acids.  Other  albuminous  bodies  are  not 
affected  by  it.  (2)  lactase,  maltase,  invertin;  they  split 
disaccharides  (milk,  malt,  and  cane  sugar)  to  monosac- 
charides,  and  each  is  stimulated  by  its  own  sugar.  (3) 
prosecretin,  which  is  changed  to  secretin  by  hydrochloric 
acid  from  the  stomach,  and  stimulates  the  secretion  of 
the  pancreas.  (4)  enterokinase,  which  activates  the  pro- 
teolytic  enzyme  of  the  pancreatic  juice;  and  probably  (5) 
diastase. 

Pancreas.  All  of  the  ferments  (trypsin,  steapsin, 
and  amylopsin)  are  found  in  the  intestines  at  birth. 

The  liver  possesses  the  ability  to  form  glycogen  and 
urea  in  the  newborn.  Bile  is  present,  its  emptying  from 
the  gall-bladder  being  stimulated  by  chemical  action  of 
fats  on  the  duodenal  mucous  membrane.  The  functions 


\ 

j  sa 


of  the  bile  are:    (1)  to  hold  fatty  acids  and  fatty jicid 
salts  Jn  solution.  (2)  to  stimulate  the  pancreas,  and  (3) 


PHYSIOLOGY   OF   THE   DIGESTIVE   TRACT.         5 

an  antiseptic  action.  Other  functions  of  the  liver  are 
formation—of—  Uiea,  and  formation  and  storing  of 
glycogen. 

Large  intestines  secrete  no  enzymes,  their  chief 
function  being  absorption  of  water  and  throwing  off  of 
Ca,  P,  Na,  K,  Fe,  Mg. 


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CHAPTER    III. 
METABOLISM    IN    INFANTS. 

1.  General  Considerations. 

THE  term  metabolism  covers  all  of  the  functions  of 
the  human  body  which  have  to  do  with  the  preparation 
for  and  assimilation  of  food. 

To  furnish  the  body  with  fuel  for  its  normal  activities, 
the  following  groups  of  food  elements  are  necessary: 
proteins,  fats,  carbohydrates,  salts,  and  water.  Fats  and 
carbohydrates,  and  to  a  lesser  extent  proteins,  furnish 
fuel;  while  the  proteins  and  salts  more  especially  form 
the  elements  necessary  for  body  growth. 

It  is  necessary  to  distinguish  between  the  activities 
which  take  place  within  the  gastro-intestinal  tract  before 
absorption  of  the  changed  products  and  the  deeper  seated 
metabolism  which  takes  place  beyond  the  intestinal  wall, 
which  can  be  designated  as  the  "intermediary  me- 
tabolism." 

Under  normal  conditions  in  the  adults  the  intake  and 
the  products  of  excretion  balance  one  another,  while  in 
the  infant  there  is  a  positive  balance — that  is,  less  is  ex- 
creted than  is  absorbed — and  one  may  well  say  that  a 
balance  which  would  be  normal  in  the  adult  is  patho- 
logical in  the  child,  and  would  thereupon  soon  result  in 
a  stationary  weight,  or  a  loss  in  weight. 

Several  factors  offer  difficulties  in  the  study  of  infant 
metabolism. 

First,  it  is  difficult  to  obtain  stools  free  from  urine  and 
with  the  water  content  intact. 

Secondly,  the  small  volume  in  which  the  urine  and 
stools  are  obtained  offers  many  difficulties  in  their  study. 

Urine  and  stool  examinations  should  cover  a  period  of 
at  least  three  days  to  be  of  conclusive  value. 

(6) 


METABOLISM    IN    INFANTS.  7 

2.  Composition  of  Milk  and  the  Metabolism 
of  Its  Constituents. 

•The  natural  food  of  the  infant  is  human  milk,  char- 
acterized by  the  fact  that  its  quality  changes  very  little, 
the  infant's  growth  being  dependent  on  the  increase  in 
amount  of  milk  secreted. 

Milk  of  different  animals  varies  as  to  its  fuel  value, 
and  also  in  its  chemical  composition,  especially  quan- 
titatively there  being  marked  differences. 

Protein          Fat  Sugar  Salts 

Human  1.5  3.5  6  to  7  0.20  per  cent. 

Cow's  3.4  3.8  4  to  5  0.75    "       " 

Human  colostrum  differs  from  the  mature  human  milk 
in  that  the  protein  and  salts  are  higher.  Protein  aver- 
aging 2.25  per  cent.,  and  the  average  ash  0.3077.  Sugar 
not  differing  greatly  from  that  the  later  milk,  but  aver- 
aging somewhat  lower.  Fats  are  also  somewhat  lower, 
averaging  3.15  per  cent.  (Holt1).  These  figures  vary 
in  different  women,  and  also  with  the  day  of  puerperium, 
but  represent  average  specimens.  Colostrum  also  con- 
tains numerous  leucocytes,  and  large  cells  containing  fat, 
these  latter  probably  being  epithelial  in  origin. 

1.  Proteins.  Chemistry  of  Proteins.  Proteins  con- 
tain carbon,  hydrogen,  nitrogen,  oxygen,  sulphur,  and 
phosphorus.  They  are  highly  complex  chemical  sub- 
stances, similar  in  their  chemical  composition  to  proto- 
plasm and  essential  to  life. 

Of  the  proteins  milk  contains  mainly  casein  and  al- 
bumins, with  small  amounts  of  globulins,  opalisin, 
nuclein,  etc. 

100  mils  of  milk  contain  Albumin  Casein 

Human  milk    0.6  Gm.  0.8  Gm. 

Cow's    milk    0.2  to  0.3  Gm.      2.7  to  3.0  Gm. 

Casein  belongs  to  the  nucleo-albumin  group  (proteins), 
which  contain  phosphorus,  are  insoluble  in  water,  mod- 


1  Amer.  J.  Dis.  Child.,  Vol.  X,  p.  228,  October,  1915. 


8  INFANT   FEEDING. 

erately  in  alkalies,  precipitated  by  acids,  not  coagulated 
by  boiling,  and  by  pepsin  digestion  changed  to  para-  or 
pseudo-  nucleins  (which  are  bodies  rich  in  phosphorus). 
Chemically  it  is  composed  of  a  complex  group  of  amino- 
acids,  the  basis  of  all  protein  bodies,  and  a  prosthetic 
group  which  contains  the  phosphorus.  Amino-acids  are 
characterized  by  the  group  COOH,  in  which  an  H  is  re- 
placed by  NH2  group,  e.g.,  acetic  acid  (CH2HCOOH), 
amino-acetic  acid,  or  glykokoll  (CH2NH2COOH). 

Human  casein  contains  much  less  phosphorus  than 
cow's  (0.25  to  0.88).  This  proves  that  the  casein  of  the 
human  and  the  casein  of  the  cow's  milk  are  different 
bodies,  although  this  difference  is  probably  of  a  quanti- 
tative nature  only.  The  two  caseins  differ  also  in  their 
coagulability,  the  human  casein  being  more  difficult  to 
precipitate  with  acids,  salts  and  rennin.  The  soluble 
albumins  are  coagulated  by  heat  and  weak  acids. 

Metabolism  of  Proteins.  Casein  is  separated  from  the 
so-called  whey  albumin,  and^is  changed  to  an  insoluble 
paranucleinx  It  is  unknown  whether  or  not  the  enzyme 
causing  it  is  identical  with  the  protein  digestive  ferment 
secreted  by  the  gastric  mucous  membrane. 

Pepsin  (from  the  pyloric  mucous  membrane)  changes 
paratluclemsTtcralbumoses  and"peptones,  which  then  pass 
into  the  small  intestines.  (Erepsin,  the  ferment  of  the 
intestinal  juices,  works  very  rapidly  on  the  end  products 
of  pepsin  digestion.)  In  the  small  intestine  an  intricate 
splitting  takes  place. 

With  the  human  milk  as  a  food,  a  very  small  amount 
of  nitrogenous  products  of  the  food  appears  in  the  stools, 
the  total  being  about  one-sixth  of  the  intake,  and  part  of 
this  arises  from 

1.  Intestinal  juices, 

2.  Intestinal  epithelium. 

3.  Bacterial  activity. 

After  passing  through  the  intestinal  wall,  proteins  have 
three  functions  to  perform : 


METABOLISM    IN    INFANTS.  9 

1.  To  replace  used  proteins  (lost  through  urine,  sweat, 
digestive  juices,  cell  destruction,  etc.). 

2.  To  satisfy  cell  growth  which  would  be  impossible 
without  proteins. 

3.  To  furnish  fuel  for  part  of  the  dynamic  loss  (fats 
and  carbohydrates  are  the  natural  fuels,  the  protein  com- 
bustion being  of  secondary  importance). 

In  the  average  feeding  with  cow's  milk,  three  times  as 
much  protein  is  given  as  needed  for  1  and  2,  therefore 
it  is  used  for  3,  (that  is,  dynamic  purpose),  or  is  rejected 
by  the  body. 

The  great  disproportion  as  seen  in  a  comparison  of 
the  proteins  in  cow's  milk  over  human  milk  is  probably 
due  to  the  needs  for  cell  growth  in  the  calf.  Due  to  the 
ability  of  the  organism,  within'  certain  limits  to  regulate 
its  function,  the  excess  of  protein  in  the  average  diet 
with  cow's  milk  as  a  basis  is  excreted  by  way  of  the 
intestinal  tract.  Cell  growth  is  therefore  not  excessively 
stimulated  on  these  relatively  high  protein  diets. 

End  Products  of  Protein  Metabolism  in  Urine: 
Urea  60  to  80  per  cent.  Ammonia  3  to  10  per  cent. 
Oxaluric  bodies  ^ 

Uric  acid  f  XT.. 

T^       .  .  >  Nitrogenous  by-products. 

Kreatinm  i 

Oxybutyric  acid  ' 

Urea  forms  75  to  86  per  cent,  of  the  nitrogen  con- 
stituents of  the  urine. 

By  ammonia  coefficient  is  meant  the  relation  of  am- 
monia to  the  other  nitrogenous  bodies  in  the  urine. 
Influence  of  the  Carbohydrates  and  Fats  on  the  Nitro- 
gen Metabolism. 

1.  Carbohydrates  cause 

(1)  Increased  retention  of  proteins. 

(2)  Increased  nitrogen  in  feces. 

2.  Fats  cause 

(1)  No  increased  protein  retention. 

(2)  Increased  nitrogen  in  feces. 


10  INFANT   FEEDING. 

2.  Fats.  Chemistry  of  Fats.  Human  milk  fats  are 
esters  of  palmitic,  stearic,  and  oleic  acids  with  glycerin, 
the  oleic  acid  ester  being  present  in  larger  amount  in 
human  than  in  the  cow's  milk.  Human  milk  fats  are  de- 
rived partly  from  body  fat  and  partly  from  food  fat. 
Carbohydrates  also  furnish  ingredients  for  fat  making; 
proteins  do  not. 

Metabolism  of  Fats. 

1.  Lipase  from  the  gastric  mucous  membrane  causes 
some  splitting  of  fat. 

2.  Fats  are  emulsified  in  small  intestines. 

3.  Live  intestinal  cells  can  change  fatty  acids  to  fats. 

f 

Resorption. 

1.  Lymph-vessels. 

2.  Blood-vessels. 

Disposition. 

1.  Subcutaneous  tissue. 

2.  Prseperitoneal  spaces. 

3.  Liver. 

4.  Burned  with  resulting  end  products. 

(1)   Carbonic  acid.         (2)  Water. 

In  stools  found  normally  as  unresorbed  portion  of  in- 
gested fat  in  the  form  of 

1.  Fat  (neutral).      2.  Lecithin.      3.  Cholesterin. 

4.  Fatty  acids  representing  1  to  10  per  cent,  of  fat 

ingested. 

5.  Alkali  soaps.      6.  Earthy  alkali  soaps. 

In  Urine.  Fatty  acids  and  glycerin  are  found  in  very 
small  quantities,  but  we  cannot  say  that  these  are  from 
the  fats  ingested. 

Nursing  babies  always  have  at  least  a  small  amount  of 
fat  in  their  stools.  In  contradistinction  to  proteins,  the 
fats  in  the  stools  are  in  greater  part  only  unresorbed  fats, 
only  a  small  amount  being  due  to  cell  activity.  (Proteins 
greater  part). 


METABOLISM    IN    INFANTS.  11 

Various  percentages  of  fat  ingredients  found  by 
Klotz  in1  examination  of  breast  milk  stools  are  as  follows : 

Neutral  fat   29.5  per  cent. 

Fatty  acids 10.7    "       " 

Combined  fatty  acids  ....  58.8    "       "       (18.3  Ca  and  Mg.) 

While  under  normal  conditions  18.3  per  cent,  of  the 
fats  in  the  stools  exist  as  non  absorbable  fat  soaps  in 
the  so-called  fat  soap  stools,  they  will  approximate  50 
per  cent,  of  calcium  and  magnesium  soap. 

Fat  in  the  G astro-intestinal  Tract  and  its  Relation  to 
Metabolism.  Unlike  proteins  we  can  nourish  the  in- 
dividual without  fats,  as  carbohydrates  can  replace  them. 
If  too  long  continued,  the  organism  changes,  however,  in 
its  chemistry  through  increased  absorption  of  salts  and 
water. 

3.  Carbohydrates.  Milk  sugar  formed  by  the  mam- 
mary glands  from  material  circulating  in  the  blood  is  a 
disaccharide  (glucose  and  galactose). 

Chemistry  of  Carbohydrates. 

1.  Monosaccharides. 

(1)  Glucose  (dextrose,  grape  sugar).  7S  ' 

(2)  Lsevulose  (fruit  sugar).  ,£_K_ 

They  ferment  and  are  reducible.     (1)  Has 
a  right  and  (2)  left  polarization. 

2.  Disaccharides. 

(1)  Lactose — glucose  and  galactose. 

(2)  Maltose — glucose  and  glucose. 

(3)  Saccharose — glucose  and  Isevulose. 
(1).  and  (2)  are  reducible,  (3)  is  not. 

3.  Polysaccharides  (three  or  more  sugar  molecules). 

(1)  Flour. 

(2)  Dextrin. 

(3)  Cellulose. 


1  Langstein-Meyer :  Wiesbaden,  Verlag  von  J.  F.  Bergmann. 
Third  edition,  p.  16. 


12  INFANT   FEEDING. 

'Metabolism  of  Carbohydrates.  Monosaccharides  are 
without  further  change  absorbed  in  the  small  intestine 
or  fermented. 

Disaccharides  are  first  reduced  to  monosaccharides  by 
the  intestinal  ferments  (every  disaccharide  having  its 
specific  ferment)  before  they  can  be  absorbed.  (This  is 
not  entirely  true  of  maltose). 

Polysaccharides  are  first  acted  upon  by  ptyaline  in  the 
saliva ;  this  is  continued  in  the  stomach  until  the  stomach 
content  becomes  acid,  and  then  by  enzymes  of  intestines 
and  pancreas  they  are  converted  to  monosaccharides. 

After  absorption  into  the  blood,  the  carbohydrates 
serve  the  following  purposes : 

1.  Used  for  energy. 

2.  Synthetically  inverted  into  glycogen. 

3.  Fat  foundation  (probably). 

Body  cells  can  oxidize  only  monosaccharides  (maltose 
excepted). 

Interesting  is  the  storing  up  of  glycogen  by  the  liver 
and  muscles  so  that  the  sugar  in  the  blood  can  be  kept 
constantly  at  about  0.1  per  cent. 

Glycogen  is  most  easily  made  from  glucose  and  Isevu- 
lose;  less  so  from  galactose,  maltose  and  starch;  least 
easily  from  cane  and  milk  sugar.1  2 

Fat  is  formed  from  sugar  by  the  subcutaneous  cells, 
which  are  especially  adapted  to  this  function.2 

Sugar  is  oxidized  to  carbon  dioxide  and  water,  which 
can  be  measured  by  the  respiratory  metabolism.  Nor- 
mally, sugar  is  absorbed  from  the  small  intestines,  and 
is  not  found  in  the  feces. 

Sugar  appears  in  the  urine  when  the  capacity  for 
assimilation  is  passed,  thereby  producing  an  alimentary 
glycosuria.  This  is  most  easily  accomplished  in  the 

1  Otto  von  Furth:  Physiological  and  Pathological  Chemistry 
of  Metabolism.     J.  B.  Lippincott  Company,  p.  227-230. 

2  Langstein  and  Meyer :  J.  F.  Bergmann,  Wiesbaden,  1914,  Third 
Edition,  p.  16. 


METABOLISM    IN    INFANTS.  13 

following  order:  lactose,  galactose,  laevulose,  glucose. 
The  cane  sugar  limit  is  about  the  same  as  milk  sugar, 
while  that  of  malt  sugar  is  7.7  grams  per  kilogram  body 
weight.  The  assimilation  limit  for  sugars  is  much 
greater  in  infants  than  in  adults.  An  infant  may  develop 
mellituria  when  milk  sugar  exceeds  3.1  to  3.6  grams 
per  kilogram  body  weight;  in  the  adult  at  over  1  gram 
per  kilogram.  The  height  of  the  assimilation  limit  in 
itself  shows  that  the  infant's  organism  is  adapted  to  a 
higher  carbohydrate  metabolism  than  that  of  the  adult. 

Carbohydrates  in  the  Tissues.  The  newborn  has  a  gly- 
cogen  reserve  which  helps  to  sustain  it  until  the  appear- 
ance of  the  mother's  milk. 

Carbohydrates  can,  in  part  at  least,  replace  proteins 
and  fats.  They  cause  a  rapid  increase  in  weight  (very 
rapid  at  first),  being  deposited  in  the  tissues,  as  glycogen, 
which  latter  can  absorb  two  to  three  times  its  weight  of 
water. 

The  relation  of  fats  to  carbohydrates  is  as  follows: 

The  more  carbohydrates  present,  the  greater  is  the  ten- 
dency on  the  part  of  the  system  to  build  up  body  fats. 
As  to  oxidation  of  fats,  "They  are  burned  up  in  the  fire 
of  carbohydrates"  (Naunyns). 

The  complete  burning  of  fats  into  carbon  dioxide  and 
water  takes  place  only  when  the  carbohydrate  metabolism 
is  normal;  otherwise  we  get  as  mid-products  the  acetone 
bodies  (acetone,  aceto-acetic  acid,  oxybutyric  acid,  etc.). 

They  occur  most  frequently  in  infancy  and  childhood 
following  periods  of  underfeeding  or  starvation.  (Im- 
portant in  infants'  disease,  as  seen  during  weaning, 
anorexia,  continued  fevers,  intoxication,  etc.) 

Acetone  bodies  can  also  be  formed  from  protein  mole- 
cules. This  occurs  in  starvation  and  in  excessive  meat 
and  fat  diets  (deficiency  of  carbohydrates  in  the  latter). 

Weight  becomes  stationary  or  a  loss  results  when  car- 
bohydrates are  excluded  or  insufficient  in  the  diet.  Tern- 


14  INFANT   FEEDING. 

perature  falls,  and  does  not  rise  to  normal  until  they  are 
replaced. 

4.  Salts.  Chemistry  of  Salts.  Salts  added  to  water 
are  relatively  split  into  their  "ions" — that  is,  into  either 
electrically  positive  or  negative  bodies.  A  solution  of 
sodium  chloride  is  a  solution  in  which  the  NaCl  molecule 
is  intact,  but  the  Na  (kation)  is  electro-positive;  the  Cl 
(anion)  is  electrically  negative. 

Mature  human  milk  contains  0.2  Gm.  ash  in  100  mils. 
Cow's  milk  0.75  Gm.  ash  in  100  mils.  Some  exists  as 
inorganic  salts,  others  as  important  organic  compounds. 

I.  Kations  (or  cations). 

1.  Calcium. 

(1)  Human  0.458  Gm.  per  1000  mils,  cow's  1.72 

Gm.  per  1000  jnils,  about  1 : 4. 

(2)  Excretion  is  almost  entirely  through  intes- 

tines, some  from  unabsorbed  food  rem- 
nants, and  the  rest  by  tissue  metabolism. 

2.  Magnesium. 

(1)  Human  0.074  Gm.   per   1000  mils,   cow's 

0.2  Gm.  per  1000  mils. 

(2)  Its  metabolism  is  very  closely  related  to  the 

calcium. 

3.  Sodium.    4.  Potassium. 

(1)  Human  milk  0.132  Gm.  Na2O,  cow's  0.465 

Gm.  Na2O  per  1000  mils,  1 :  3. 

(2)  Human  milk  0.609  Gm.  K2O,  cow's  1.885 

Gm.  K2O  per  1000  mils,  1 :  3. 

(3)  Excretion    mostly    through    kidneys    and 

stools. 
5.  Iron. 

Human  milk  0.0017  Gm.  cow's  0.0007  Gm.  per 
1000  mils.  These  figures  show  consid- 
erable variation  according  to  different 
authors.  Excreted  mainly  through  the 
bowels. 


METABOLISM    IN    INFANTS.  15 

II.  Anions. 

1.  Chlorine. 

Human  0.358  Gm.,  cow's  0.82  Gm.  per  1000 
mils,  1:3. 

(1)  Absorption:    90  to  100  per  cent,  through 

the  intestine. 

(2)  Excretion:    mostly  through  kidneys. 

(3)  About  0.5  per  cent,  retained  by  the  system. 

2.  Phosphorus  is  contained  in  the  milk  in  the  fol- 

lowing forms: 

(1)  Inorganic  (calcium  phosphate). 

(2)  Organic  (casein,  nuclein,  lecithin,  etc.). 

(3)  Total  in  human  0.345  to  0.418  Gm.,  in  cow's 

2.437  Gm.  per  1000  mils,  1 : 9. 

(4)  Organic  in  human  43.3  per  cent.,  and  cow's 

46  per  cent,  1:1. 

(5)  The  retention  is  higher  in  artificially  fed 

than  those  fed  on  human  milk. 

Relation  of  Salts  to  Metabolism.  The  salts  are  neces- 
sary in  digestion  and  in  every  step  of  metabolism  from 
absorption  to  excretion  and  secretion.  The  role  of  these 
salts  in  both,  normal  and  pathological  conditions  has  been 
given  constantly  increasing  importance  in  the  last  few 
years. 

Metabolism  of  Salts  in  Infants.  In  the  gastro-intes- 
tinal  tract  the  foods  and  salts  are  constantly  changing 
action. 

A  casein  product  and  calcium  combine  in  the  stomach 
to  form  calcium  paracasein. 

Fatty  acids  and  alkalies  and  earthy  alkalies  in  the  intes- 
tines form  soaps. 

Casein  increases  excretion  of  salt  in  the  intestine 
(moderate). 

Fat  increases  excretion  of  salts  in  the  intestines 
markedly,  (especially  Ca,  Na,  K).  At  the  same  time  the 
phosphorus  excretion  decreases  as  the  calcium  phosphates 
are  changed  to  calcium  soaps  by  combination  of  calcium 


16  INFANT   FEEDING. 

with  fatty  acids,  and  the  free  phosphoric  acid  unites  with 
sodium  and  potassium  to  form  easily  absorbed  salts. 

Salts  are  excreted  in  the  urine  and  stools.  The  stools 
are  the  main  channel  of  excretion  of  calcium,  magnesium, 
and  iron.  Whether  these  are  formed  from  the  tissues  or 
unabsorbed  food  is  difficult  to  decide.  The  difference  in 
percentages  in  human  and  cow's  milk  is  equalized  by  the 
body  using  only  what  is  necessary  to  its  life  and  growth 
and  not  attempting  to  use  it  all. 

Functions  of  Salts. 

(1)  They  furnish  building  material  for  new  cells. 

(Rachitis  due  to  lack  of  absorption.) 

(2)  They  are  necessary  to  nerve  excitability,  muscle 

contraction,  and  many  other  vital  functions. 

(3)  Addition  of  calcium  and  potassium  to  normal 

salt  solutions  counteracts  their  poisonous 
effects. 

(4)  Life  is  incompatible  with  withdrawal  of  min- 

erals or  even  one  ion. 

(5)  Life  does  not  so  much  depend  upon  the  ion  as 

on  its  chemical  combination.  Therefore  ash 
alone  will  not  supply  the  needs. 

(6)  Infants  need  minerals  for  growth,  as  well  as 

for  life.  Different  tissues  require  different 
amounts  and  different  salts. 

(7)  Weight  drops  with  withdrawal  of  salts,  even 

if  other  ingredients  are  constant,  due  to  loss 
of  water.  Sodium  salts  are  most  important 
in  water  retention,  calcium  •  salts  are  least. 

(8)  Temperature  falls,  when  salts  are  withdrawn 

(sodium). 

(9)  Phagocytosis  is  increased  by  calcium  salts.    Of 

value  in  infection. 

5.  Water.  Infants  need  105  Gm.  of  water,  and  adults 
40  Gm.  of  water,  per  Kg. 

Metabolism  of  Water.  Intake  is  in  the  food.  The 
outgo  from  the  kidneys,  bowels,  lungs,  and  skin. 


METABOLISM    IN    INFANTS.  17 

Water  when  ingested  quickly  passes  through  the  stom- 
ach to  be  absorbed  by  the  intestines.  The  water  content 
of  the  organism  varies  with  age  and  food.  In  the  adult 
58  per  cent,  of  body  is  water,  and  in  the  newborn  infant's 
body  66  to  69  per  cent,  is  water.  Sodium  salts  have  the 
greatest  facility  for  water  retention. 

Of  the  anions,  Cl  is  the  most  marked  in  causing  water 
retention. 

Excretion  of  water  takes  place  as  follows :  kidneys  59 
per  cent.,  skin  and  lungs  33  per  cent.,  intestines  6  per 
cent.  One  to  2  per  cent,  of  the  water  intake  is  retained. 

Relation  of  Water  to  Metabolism.  Approximately 
two-thirds  of  the  infant's  body  is  water.  All  cells  need  it ; 
it  is  necessary  to  different  combinations  and  reactions.  In 
general,  it  is  necessary  for  young  infants  on  artificial 
feeding  to  receive  about  140  to  150  mils  (4  to  5  ounces) 
per  kilogram  (2  pounds)  body  weight  every  twenty-four 
hours.  It  carries  nutritious  material  in  the  blood,  lymph, 
cells,  etc.,  and  also  the  material  for  anabolism  and  kata- 
bolic  products.  It  is  also  necessary  to  the  function  of  the 
lungs  and  of  the  skin.  Immunity  to  infection  is  to  a 
large  extent  dependent  on  the  water  content  of  the  body. 

6.  Lipoids.  Proteins  and  lipoids  form  the  principal 
component  parts  of  all  living  cells.  The  lipoids  are  a 
group  of  organic  nitrogenous  substances  comprising  the 
phosphatids,  cerebrosids  and  cholesterin.  The  phospha- 
tids  contain  phosphorus,  an  organic  base,  and  a  fatty 
acid  radicle  in  their  molecule.  The  members  of  this 
series  are  lecithin,  cephalin  and  cuorin.  They  are  widely 
distributed  in  both  animal  and  vegetable  cells,  but  are 
especially  abundant  in  the  yolk  of  eggs,  fish  roe,  brain 
tissue,  yeast,  blood  and  bile.  They  are  also  found  to 
a  lesser  extent  in  cereal  grains,  legumes  and  beet  root. 
The  cerebrosids  are  isolated  almost  entirely  from  brain 
and  nerve  tissue.  These  do  not  contain  phosphorus  and 
yield  galactose  upon  hydrolysis  with  dilute  mineral  acids. 
Cholesterin  is  an  unsaturated  secondary  alcohol,  is  uni- 

2 


18  INFANT   FEEDING. 

versally  present  in  animal  and  vegetable  tissue,  and  is 
most  abundant  in  bile,  yolk  of  eggs,  nerve  tissue  and 
wool  fat,  and  found  abundantly  in  wheat,  barley,  beans, 
peas,  lentils,  carrots,  peanuts  and  beets. 

Lecithin.  Lecithin  is  the  fatty  acid  ester  of  the  glycero- 
phosphates  (glycerin  phosphoric  acid),  Human  milk, 
0.499  Gin.  per  1000  Gm. ;  cow's,  0.63  Gm.  per  1000  Gm. 

Cholesterin.  Human  milk,  0.25  to  0.38  Gm.  per  1000 
Gm.  Mainly  excreted  by  the  intestines. 

This  is  of  interest  when  we  consider  that  fat-free  milk 
contains  but  little  lipoids. 

7.  Vitamines.  The  term  is  used  to  cover  a  group  of 
substances  the  chemical  nature  of  which  has  as  yet  not 
been  determined.  These  compounds  are  absolutely  es- 
sential in  food,  in  order  to  maintain  the  weight  of  the 
body  and  produce  growth.  The  lack  of  sufficient  vita- 
mines  causes  deficiency  diseases,  so  named  because  they 
are  due  to  a  lack  of  something  in  the  diet.  It  is  unknown 
whether  they  exert  their  action  directly  on  the  tissues  or 
indirectly,  as  has  been  suggested,  through  a  hormone  ac- 
tion. They  cannot  be  produced  by  the  animal  organisms 
or  are  produced  in  such  limited  amounts  that  they  are 
insufficient  to  meet  the  body  needs.  For  this  reason  we 
are  dependent  upon  the  supply  contained  in  the  diet  for 
these  essential  factors. 

Lower  forms  of  animal  life,  such  as  yeast  cells,  seem 
able  to  elaborate  vitamines,  and  plant  cells  possess  this 
faculty  to  a  high  degree.  It  is  also  impossible  for  the 
body  to  store  them  to  any  extent.  Therefore  it  is  neces- 
sary that  the  food  contain  a  constant  supply. 

Tentatively  they  are  grouped  according  to  their  solu- 
bility in  fat  and  water  and  it  may  be  hoped  that  a  more 
scientific  terminology  will  soon  be  applied  to  them  when 
their  chemical  nature  is  better  understood.  At  present 
they  are  described : 

1.  Fat-soluble  A  vitamine  (growth  promoting).  C«A'" 


METABOLISM    IN    INFANTS.  19 

2.  Water-soluble    B    vitamine     (growth    promoting 

and  anti-neurrtic). 

3.  Water-soluble  C  vitamine  (anti-scorbutic). 

The  Fat-soluble  A  vitamine  is  thirty  times  as  soluble 
in  fat  as  in  water.  It  is  found  in  cod-liver  j)il,  egg-yolk, 
butter,  creamand  mi]k.  Because  of  the  greater  solubility 
in  fats  it  is  about  equally  distributed  between  the  cream 
and  the  fat-free  portion  of  the  milk.  It  is  contained  in 
beef  and  mutton  fat  but  little  or  none  is  found  in  lard 
and  the  commercial  vegetable  oils.  It  is  found  in  con- 
siderable quantities  in  the  heart,  kidneys,  liver  and  the 
glandular  organs.  The  leaves  of  plants  are  rich  in  it, 
while  the  seeds  and  root  vegetables  contain  less. 

The  Water-soluble  B  vitamine  is  one  of  the  essentials 
in  the  promotion  of  growth.  It  is  found  in  yeast,  fruit 
juices,  vegetables  and  grain  embryos.  The  leafy  vege- 
tables and  those  growing  above  the  ground,  such  as  to- 
matoes and  celery  contain  it  in  larger  proportions  than 
the  root  vegetables,  such  as  potatoes,  carrots,  and  turnips. 
It  is  also  present  in  milk  and  egg-yolk.  When  cereals 
are  very  highly  milled  in  order  to  obtain  a  very  fine 
white  flour,  a  large  part  of  the  vitamines  may  be  re- 
moved. Vitamines  are  also  lost  when  rice  is  polished  in 
order  to  remove  the  outer  layers,  which  contain  most  of 
the  vitamines. 

The  Water-soluble  C  vitamine  is  known  as  anti-scor- 
butic vitamine.  It  is  found  in  oranges,  grapefruit,  lem- 
ons and  other  citrus  fruits  (these  contain  both  B  and  C), 
and  in  green  vegetables  such  as  tomatoes,  spinach,  lettuce 
and  cabbage,  and  in  eggs  and  raw  milk.  It  is  present 
in  actively  living  cells,  so  that  in  general  those  vegetable 
tissues  which  contain  relatively  large  numbers  of  actively 
respiring  cells  (leafy  vegetables),  are  richer  in  anti- 
scorbutic power  than  are  the  roots  or  tubers.  This  gen- 
eralization is  not  without  exception.  Different  vegetables 
and  fruits  vary  greatly  in  their  anti-scorbutic  potency. 
They  differ  widely  also  in  the  extent  to  which  their  anti- 


20 


INFANT   FEEDING. 


scorbutic  value  will  deteriorate  under  certain  physical 
and  chemical  conditions  (drying,  alkalinizing,  etc.). 
From  the  above  statement  it  is  apparent  that  the  anti- 
scorbutic potency  of  foodstuffs  varies  directly  with  the 
quantity  contained. 

For  further  facts  on  vitamines  see  Nutritional  Dis- 
turbances due  to  Insufficient  Vitamines,  page  215,  and 
Scurvy,  page  364. 


Classes    of    Foodstuff 

Fat-soluble   A 
or  Anti- 
rachitic 
Factor 

Water-Solu- 
ble  B  or  Anti- 
neuritic     (An- 
tiberiberi) 
.  Factor 

Antiscor- 
butic 
Factor 

Fats  and  Oils: 
Butter         

4-  4- 

Cod-liver  oil    

4-  4- 

Beef   fat  or   suet    

4-  4- 

Fish  oil,   whale  oil,   etc.    ... 
Margarin       prepared      from 

Value  in  pro- 

portion     to 
amount      of 
animal       fat 
contained 

4- 

Meat,  Fish,  etc.: 
Lean    meat    (beef,    mutton, 
etc  )  

4- 

4- 

4. 

+  + 

4-  4- 

I 

Kidneys    

Heart    

i     i 

+ 

Brain    

4- 

4- 

i     i 

Fish     white 

very  slight    if 

Fish,    fat    (salmon,    herring, 
etc.)    

any 
very  slight,  if 

any 
+  + 

? 

Milk,   Cheese,  etc.: 
Milk,  cow's  whole,  ra%  

4.4. 

_i_ 

X 

Milk    dried  whole   

less  than  4  —  h 

4- 

less  than  4~ 

Milk    boiled,    whole    

undetermined 

4- 

less  than  4~ 

Milk,    condensed,   sweetened 
Cheese,   whole  milk   

4- 

less  than  4- 

Eggs: 
Fresh    

4-4-4- 

Dried    

. 

4-4-4- 

• 

Cereals,  Pulses,  etc.: 
Wheat,    maize,    rice,    whole 
grain  

4- 

4- 

Wheat  germ   

METABOLISM    IN    INFANTS. 


21 


Classes  of  Foodstuff 

Fat-soruble  A^^Sti- 
°r   h?H          neuritic    (An- 
rachitic             tiberiberi) 
Factor                Factor 

Antiscor- 
butic 
Factor 

('cmilx,   I'nlxcx,  etc.: 
(continued). 
Wheat,  maize,  bran   

4.  4. 

Linseed,    millet    

4-4-                  4-  4.    . 

Dried   peas,    lentils,    etc  

4  —  L. 

Soy  beans,  haricot  beans   .  . 
Germinated    pulses    or    cer- 

4-                            4-4- 

i     i 

Yegctables   and   Fruitx: 
Cabbage    fresh  (raw)  

4-4-                      4- 

i     i     i 

Cabbage   fresh  (cooked)  .... 

_L 

Cabbage    dried  

... 

Cabbage,  canned  

Swede    (rutabaga)    raw    ex- 
pressed juice  

4-4-4- 

4.4-                  4. 

Spinach  (dried)  

4-4-                    4- 

Carrots    fresh  raw  

4-                       4. 

Beetroot,      raw,      expressed 
juice    

4. 

4-                      4- 

4. 

Beans,    fresh,    scarlet    run- 

4.  4. 

Lemon  juice    fresh   

4  —  |  —  (_ 

4.  4. 

Lime  juice   fresh  

Lime   juice    preserved    

Orange  juice    fresh   

4-4-4- 

4.  4. 

+             !""+ 

T                | 

4-  4. 

Nuts         

4-                      4-4. 

Miscellaneous: 
Yeast    dried   

4.4.4- 

Yeast,  extract  and  autolysed 

?                       4  |  (_ 

specimens 

None  of  the  three  factors  were  found  in: 

Lard. 

Olive,  cottonseed,  coconut  or  linseed  oils. 

Coco  butter. 

Hardened  fats,  animal  or  vegetable  in  origin. 

Margarin  from  vegetable  fats  or  lard. 

Cheese  from  skim  milk. 

Polished  rice,  white  wheaten  flour,  pure  cornflour,  etc. 

Custard  powders,  egg  substitutes,  prepared  from  cereal  products. 

Peaflour    (kilned). 

Meat  extract. 

Beer. 


Report  published  by  a  Committee  appointed  jointly  by  the  Lister  In- 
stitute and  the  Medical  Research  Committee. 


22  INFANT   FEEDING. 

3.  Milk  Digestion. 

1.  In  the  Mouth.    In  the  mouth  milk  is  mixed  with 
saliva,  each  100  mils  of  milk  averaging  about  5  mils  of 
saliva  (Tobler).     The  secretion  of  saliva  is  stimulated 
mainly  by  the  act  of  sucking,  but  also  in  part  by  appetite 
(psychic  reflex).    Ptyalin  begins  its  action  on  the  carbo- 
hydrates of  the  milk.  Saliva  may  also  cause  coagulation. 

2.  In  the   Stomach.      In   the   stomach   the   milk   is 
curdled,  casein  being  precipitated  by   rennin.     Human 
milk   coagulates  less   rapidly  and   less   completely  than 
cow's  milk.     Therefore  in  the  latter  the  curds  and  the 
whey  are  more  quickly  separated. 

Proteins  are  changed  to  albumoses  and  peptones  by 
pepsin,  and  thus  they  are  prepared  for  further  digestion 
in  the  intestine.  Albuminous  digestive  products  stimu- 
late gastric  secretion. 

Of  fats  25  per  cent,  are  changed  to  fatty  acids  and 
glycerin  by  lipase  and  action  of  bacteria.  Fats  at  first 
retard,  and  later  increase,  the  gastric  secretion. 

Action  of  ptyalin  on  Carbohydrates  is  continued  for  a 
time  in  the  fundic  end  of  the  stomach. 

Absorption  in  the  stomach  is  as  follows:  (1)  salts  and 
sugars,  (2)  proteins  (small  amounts),  (3)  water  (none), 
(4)  fats  (none). 

Shortly  after  beginning  of  the  nursing  some  of  the 
whey  content  of  the  food  begins  to  leave  the  stomach. 
This  is  more  especially  true  if  the  ferments  are  active. 
The  time  also  varies  with  the  quality  of  the  meals. 
Human  milk  leaves  the  stomach  in  about  one  and  one- 
half  to  two  hours  after  ingestion,  and  cow's  milk  in  about 
three  hours  after  ingestion.  Two  factors  have  an  impor- 
tant bearing  on  this  point:  (1)  the  quantity  of  the  fat, 
which  delays  the  passage  of  the  food  through  the  pylorus, 
(2)  the  size  of  the  curds,  the  large  curds  of  the  cow's 
milk  delaying  emptying  of  the  stomach. 


METABOLISM    IN    INFANTS.  23 

As  previously  stated,  whey  quickly  passes  out  of  the 
stomach,  and  remaining  curd  is  digested  at  its  surface, 
and  thus  passes  over.  Solid  masses  may  pass  through. 
After  each  passage  of  food  the  pylorus  again  closes.  The 
rapidity  of  emptying  the  stomach  depends  on  the  action 
of  the  pylorus,  and  this  in  turn  on  the  chemical  composi- 
tion of  the  food.  Fats  and  albumins  remain  long  in  the 
stomach,  sugars  and  salts  passing  through  more  rapidly. 

3.  In  the  Small  Intestines.    The  action  of  the  gastric 
digestion  on  the  proteins  is  supplemented  by  trypsin  from 
the  pancreas,  and  the  erepsin  of  the   succus  entericus. 
End  products  of  the  protein  digestion  are  amino-acids. 
Carbohydrates    are    split    into    monosaccharides    in    tjie 
small  intestines  and  are  absorbed  there.    Fats  which  have 
been  split  into  fatty  acids  and  glycerin  are  emulsified  and 
absorbed.     Absorption   of   all   digested   food   is   almost 
complete  in  small  intestines.    It  may  be  stated  that  intes- 
tinal or  pancreatic  digestion  is  far  more  important  than 
gastric  digestion  in  the  infant. 

4.  In  the  Large  Intestines.    Absorption  of  water  and 
excretion  of  salts  are  the  chief  functions  of  the  large 
intestines  in  the  digestive  process. 

5.  Feces  and  Urine.    Feces  is  composed  of  food  rem- 
nants, products  of   secretory  activity  of  the  intestines, 
desquamated    mucosa    of    the    intestines,    and    bacteria. 
Composition  of  feces  depends  to  a  certain  extent  upon  the 
nature  of   the   food   ingested.     Foods   rich   in  proteins 
(skim  milk,  albumin  milk,  etc.)   cause  increased  intes- 
tinal  secretion,   with    resulting  alkaline   reaction,    which 
favors  putrefaction  and   furnishes  conditions   favorable 
for  development  of  fat  soap  stools.    Excess  of  carbohy- 
drates   with    acid    fermentation    gives    another    picture. 
Putrefaction  and  fermentation  work  antagonistically  on 
the  reaction  of  the  stool.    There  is  a  balance  between  the 
acids  derived  from  fat  and  sugars  by  bacterial  action  and 
the  alkaline  intestinal  secretion, 


24  INFANT   FEEDING. 

Proteins  in  the  stool  (giving  biuret  and  Millon's  tests) 
are  in  greater  part  not  derived  from  food  proteins,  but 
they  are  due  to  intestinal  secretions,  desquamated  epi- 
thelial cells  of  the  intestines,  and  to  the  bodies  of  bac- 
teria. This  is  especially  true  of  breast-fed  infants.  The 
normal  infant  stool  contains  no  unchanged  casein. 

Fat  has  an  important  influence  upon  the  formation  of 
the  stool.  On  feeding  with  human  milk  poor  in  fat  the 
stools  are  small,  containing  small  quantities  of  solids  and 
some  mucus.  On  feeding  with  human  milk  which  is  rich 
in  fat,  normal  stools  are  produced.  Microscopically  fat  is 
always  evident  in  stools,  and  is  derived  partly  from  food, 
and  in  small  quantities  from  the  secretion  of  intestinal 
juices.  Fatty  acids  and  fat  soaps  are  constantly  found. 

Salt  excretion  is  an  important  function  of  the  large 
intestine.  In  the  breast  fed,  ash  content  of  dry  stool  is 
10  per  cent.,  bottle  fed  40  per. cent.  Insoluble  calcium 
salts  harden  the  feces. 

The  following  are  some  tests  on  constituents  of  feces : 

1.  Fat  soap  easily  seen  as  fatty  acid  crystals  (needles) 
by  heating  with  acetic  acid  on  the  cover  glass  and  allow- 
ing to  cool. 

2.  Carbofuchsin  in  weak  solution  stains  as  follows: 
Neutral  fat:   no  stain.     Soaps:    faint  rose  color.     Fatty 
acids :   red. 

3.  Sudan   III  stains  as   follows:  Neutral   fat:  orange 
red.     Soaps :    crystals  do  not  stain.     Fatty  acids :    stain 
red  or  crystals,  orange  red. 

4.  Sugar  is  not  demonstrable  in  any  quantity  as  such, 
but  the  character  of  the  fat  soap  stool  seen  in  milk  feed- 
ing without  sugar  is  changed  to  a  softer,  smaller,  and 
normal  color  by  adding  sugar. 

5.  Starch  is  demonstrable  by  iodine  test  microscopic- 
ally, but  care  must  be  exercised  in  the  interpretation  of 
the  test,  as  the  starch  may  be  derived  from  baby  powders. 

The  color  of  the  stool  is  due  to  bile  coloring  matter  de- 
rivatives: bilirubin  and  its  reduction  products,  urobilin 


METABOLISM    IN   INFANTS.  25 

and  urobilinogen.  The  less  the  bile  pigments  are  reduced, 
the  more  colored  the  stools.  By  marked  reduction  to 
urobilinogen,  the  color  becomes  almost  white.  The  more 
milk  and  cream,  i.e.,  fat,  in  the  diet,  the  paler  the  feces. 
The  so-called  soap  stool  is  due  to  excess  of  fat  and  over- 
feeding with  milk  or  cream  with  insufficient  sugar,  and 
is  a  firm  grayish,  putty-like  stool. 

Thin  watery  stools  must  always  be  taken  seriously. 
However,  the  same  cannot  be  always  said  of  green,  curdy 
stools,  which  are  not  infrequently  seen  in  thriving  breast- 
fed infants.  These  curds  are  almost  invariably  due  to 
fatty  acids  and  soaps. 

Normal  stools  of  breast-fed  infants  are  homogeneous, 
salve-like,  ochre-yellow  color,  acid,  and  of  sour  odor. 
Microscopically  may  be  seen  detritus  masses,  bacteria, 
few  neutral  fat  corpuscles,  and  fatty  acid  crystals. 

Normal  stools  of  bottle-fed  infants  vary  with  the  diet. 
One  can  frequently  tell  the  diet  by  the  appearance  of  the 
stool.  On  milk  diet:  less  frequent,  usually  1  or  2  daily, 
firmer  and  drier,  usually  pale  yellow,  alkaline  and  of  foul 
odor.  Constipation  is  the  rule  in  babies  receiving  large 
quantities  of  milk  with  a  moderate  amount  of  carbohy- 
drates. Sugars  have  a  laxative  tendency  (fermentation). 
Excess  of  brown  color  may  be  caused  by  excesses  of 
malt  sugar.  Starches,  if  well  taken,  tend  to  constipate, 
in  large  amounts  they  tend  toward  an  acid  reaction  and 
an  aromatic  odor. 

Starvation  or  hunger  stool  is  seen  on  a  very  limited 
diet,  as  minimum  amounts  of  milk,  tea,  cereal  water. 
The  stool  has  a  dark,  greenish-brown  color,  is  soft,  and 
composed  in  great  part  of  mucus,  and  appears  semi-trans- 
parent. This  mucus  may  lead  to  further  starvation 
through  mistaken  interpretation  of  its  meaning,  and  re- 
sult disastrously. 

In  the  past  it  was  taught  that  a  study  of  the  stools  gave 
one  definite  information  for  the  differential  diagnosis  of 
the  gastro-intestinal  diseases,  but  experience  has  taught  us 


26  INFANT   FEEDING. 

that  conclusions  are  of  value  only  when  based  upon  stool 
examinations  in  conjunction  with  a  careful  study  of  the 
diet,  and  clinical  examination  of  the  infant. 

Urine.  A  normal  infant  urinates  ten  to  fifteen  times 
daily,  and  the  urine  passed  represents  60  to  70  per  cent, 
of  the  fluids  taken  as  food  and  drink.  It  is  acid  in  re- 
action, and  should  be  free  from  albumin.  However,  al- 
bumin frequently  is  present  in  the  simple  nutritional  dis- 
turbances, and  almost  constantly  in  severe  acute  illnesses. 
Temporary  presence  of  albumin  in  the  urine  of  the  new- 
born may  be  considered  physiological,  as  well  as  the  uric 
acid  during  the  very  early  stage.  Great  decreases,  even 
to  anuria,  are  common  with  the  intestinal  disturbances. 


CHAPTER    IV. 

BACTERIA    OF    THE    DIGESTIVE   TRACT 
OF   THE   INFANT.* 

1.  The  Newborn. 

FOR  about  one  day  the  meconium  passed  by  the  new- 
born baby  is  sterile.  During  this  time,  however,  the  bac- 
teria begin  to  invade  the  digestive  canal  of  the  infant 
through  the  mouth  and  through  the  anus.  The  initial  in- 
testinal flora  which  thus  develops  is  subject  to  marked 
differences,  the  number  and  nature  of  the  bacteria  de- 
pending chiefly  upon  the  surroundings  of  the  infant,  and 
exhibits  no  characteristic  constant  findings. 

This  period  is  followed  by  gradual  transition  in  the 
nature  and  in  the  number  of  the  intestinal  bacteria,  until 
about  the  third  day  after  birth  characteristic  intestinal 
flora  become  established,  consisting  chiefly  of  Bacillus 
bifidus  (in  the  nursing  infant)  and  Bacillus  coli  (in  the 
artificially  fed  infant),  and,  besides  these,  Bacillus  acido- 
philus,  Micrococcus  ovalis,  Bacillus  lactis  aerogenes  and 
others. 

2.  The  Nursing  Infant. 

The  principal  portal  of  entry  of  the  intestinal  bacteria 
is  the  mouth.  There  is  no  doubt  that  a  great  variety  of 
organisms  may  from  time  to  time  enter  this  atrium,  in- 
cluding not  only  the  ordinary  organisms  of  the  nursling's 
environments,  but  pathogenic  bacteria  as  well.  A  major- 
ity of  these  pass  to  the  stomach,  and  they  may  pass  to  the 
intestinal  tract. 


*  In  the  elaboration  of  this  chapter  free  use  has  been  made  of 
A.  I.  Kendall's  Bacteriology,  Lea  &  Febiger,  Philadelphia  and 
New  York,  1916. 

(27) 


28  .          INFANT   FEEDING. 

The  flora  of  the  mouth  and  of  the  stomach  are  not 
well  known,  but  they  appear  to  be  of  relatively  slight 
importance  as  a  rule. 

The  duodenal  flora  in  health  is  composed  chiefly  of 
coccal  forms  of  the  Micrococcus  ovalis  type.  Bacillus  coli 
and  other  members  of  the  colon  group  are  most  numer- 
ous at  the  ileocecal  valve  and  the  cecum,  and  Bacillus 
bifidus  or  similar  organisms  dominate  the  large  intes- 
tines from  this  level  to  the  sigmoid  flexure.  The  re- 
mainder of  the  large  intestines  to  the  rectum  is  some- 
what sparsely  populated  with  living  bacteria,  partly  be- 
cause the  fecal  mass  is  relatively  desiccated  by  the  ab- 
sorption of  water,  partly  because  of  the  accumulation  of 
waste  products  of  bacterial  activity — principally  acids  re- 
sulting from  fermentation  of  lactose,  formed  higher  up 
in  the  tract — which  inhibit  the  development  of  bacteria 
in  the  lower  levels. 

Bacillus  bifidus  (Gram  positive,  blue  stain)  predomi- 
nates in  the  intestinal  flora  of  the  breast-fed  infant,  being 
acid  tolerant  and  finding  favorable  conditions  for  its 
growth  and  development,  since  in  digestion  of  mother's 
milk  lactic  acid  production  from  lactose  is  so  great  as  to 
inhibit  the  growth  of  the  Bacillus  coli  and  Bacillus  lactis 
aerogenes  in  the  lower  end  of  the  ileum,  while  the  highly 
acid  medium  favors  the  growth  of  the  Bacillus  bifidus 
communis  and  the  acidophile  bacteria.  Coccal  forms  and 
lactose  fermenting  organisms  are  present,  but  scanty; 
spore  bearers  are  rare. 

3.  Artificially  Fed  Infants. 

Escherich  directed  attention  to  the  striking  dissimilar- 
ity between  the  intestinal  flora  of  the  breast  fed  and  the 
artificially  fed  infant.  Culturally,  morphologically,  and 
chemically  the  former  is  more  uniform  than  the  latter. 
The  most  distinctive  features  of  the  dejecta  of  the  arti- 
ficially fed  infants  are :  the  relative  increase  of  Gram- 
negative  bacteria  of  the  coli-aerogenes  type,  and  of  coccal 


BACTERIA   OF   THE   DIGESTIVE   TRACT.         29 

forms  of  the  Micrococcus  ovalis  type,  together  with  a 
diminution  of  Bacillus  bifidus.  Bacillus  acidophilus  is 
relatively  more  numerous,  as  a  rule,  in  the  artificially 
fed  infant  than  in  the  nursling.  Proteolytic  bacteria  of 
several  types  are  also  of  frequent  occurrence,  but  they 
are  not  commonly  found  in  the  dejecta  of  the  normal 
nursling.  These  organisms  are  frequently  spore-form- 
ing bacilli,  of  which  two  principal  groups  are  recognized 
— members  of  the  aerobic  group,  of  which  Bacillus  mesen- 
tericus  is  a  prominent  type,  and  anaerobic  bacteria,  of 
which  Bacillus  aerogenes  capsulatus  is  most  widely 
known;  it  frequently  occurs  in  small  numbers  in  the 
feces  of  artificially  fed  infants.  The  reaction  of  normal 
feces  of  artificially  fed  babies  is  usually  alkaline;  cul- 
turally and  chemically,  the  evidence  of  intestinal  proteo- 
lysis  of  bacterial  causation  is  more  marked  in  these  in- 
fants than  in  normal  nurslings. 

The  general  distribution  of  types  of  bacteria  at  the 
different  levels  of  the  intestinal  tract  is  similar  to  that 
observed  in  normal  nurslings.  The  principal  differences 
are  found  in  the  cecum  and  large  intestine,  where  the 
obligately  fermentative  bacteria  of  the  bifidus  type  are 
replaced  to  a  considerable  degree  by  an  extension  of  the 
habitat  of  the  Bacillus  coli,  of  Bacillus  acidophilus,  and 
the  appearance  of  moderate  numbers  of  proteolytic  bac- 
teria, both  aerobic  and  anaerobic ;  many  of  the  latter  are 
sporogenic. 

The  characteristic  feature  of  the  normal  adult  fecal 
flora  as  compared  with  the  infantile  nursling  flora  is  the 
very  heterogeneous  variety  of  types  of  bacteria  in  the 
former,  in  sharp  contrast  to  the  homogeneity  of  types  of 
bacteria  in  the  latter. 

4.  Significance  of  the  Intestinal  Bacteria. 

The  striking  differences  in  morphology,  chemistry,  and 
in  cultural  characters  between  the  intestinal  floras  char- 
acteristic respectively  of  nurslings,  artificially  fed  infants 


30  INFANT   FEEDING. 

and  adults  suggest  at  once  that  nutritional  stimuli  may  be 
an  important  factor  in  determining  the  dominance  of 
type  of  bacteria.  It  is  probable  that  the  significance  of 
the  intestinal  flora  lies  rather  in  its  potential  antagonism 
to  alien  bacteria,  which  certainly  gain  entrance  to  the 
alimentary  canal  from  time  to  time,  than  in  any  specific 
participation  in  the  normal  digestive  process  of  the 
host.  The  normal  intestinal  flora  may  be  regarded  as  intes- 
tinal parasites,  just  as  the  various  bacteria  which  occur 
commonly  on  the  skin  are  regarded  as  cutaneous  para- 
sites. It  is  important  to  realize  that  the  normal  intestinal 
organisms,  like  the  cutaneous  organisms,  are  "oppor- 
tunists," potentially  capable  of  becoming  invasive  when- 
ever the  barriers  which  ordinarily  suffice  to  limit  their 
development  to  the  lumen  of  the  alimentary  canal  become 
impaired,  giving  rise  to  endogenous  infections. 

5.  Influence  of  the  Diet  on  the  Intestinal  Flora. 
Intestinal  flora  vary  greatly,  the  most  important  fac- 
tor in  determining  its  nature  being  the  chemical  composi- 
tion of  the  food.  Human  milk  gives  essentially  different 
flora  from  cow's  milk.  There  are  two  groups  of  bacteria 
possessing  an  antagonistic  action,  those  causing  fermen- 
tation (saccharolytic),  and  those  causing  putrefaction 
(proteolytic).  The  representatives  of  the  former  are  Bac- 
illus lactis  aerogenes  and  Bacillus  bifidus,  the  latter  being 
the  most  important  organism  in  the  stool  of  the  breast-fed 
infants.  The  group  exercising  proteolytic  activity  is  less 
clear.  We  know  only  that  in  the  processes  of  putrefac- 
tion the  bifidus  flora  is  replaced  by  the  coli  group.  De- 
pending on  the  predominating  group  of  bacteria,  putre- 
faction or  fermentation  takes  place,  causing  either  firm 
or  soft  stools,  this  rather  than  the  activity  of  the  ferments 
determining  the  nature  of  the  stools.  The  nature  of  the 
food  and  its  chemical  composition,  therefore,  determines 
the  nature  of  the  development  and  activity  of  the  par- 
ticular bacteria  in  the  intestinal  tract. 


BACTERIA    OF   THE   DIGESTIVE   TRACT.          31 

The  human  milk,  rich  in  sugar  and  low  in  protein,  leads 
to  the  flora  of  fermentation,  while  cow's  milk,  rich  in 
protein  and  poor  in  sugar,  to  the  flora  of  putrefaction. 
This  phenomenon  is  nothing  specific,  but  is  due  to  in- 
dividual components  of  the  milk  and  their  mixture. 

Carbohydrates  lead  to  the  development  of  the  fermen- 
tative organisms;  the  split  products  of  carbohydrates  are 
acetic,  butyric,  lactic  and  carbonic  acids. 

The  nature  of  the  dominant  organisms  which  develop 
in  diets  rich  in  carbohydrates  varies  with  the  carbohy- 
drate itself.  Bacillus  bifidus  is  more  commonly  predom- 
inant when  lactose  is  the  sugar  fed,  without  an  excess  of 
protein.  If  maltose  or  dextrose  is  substituted  for  lactose 
under  the  same  conditions,  Bacillus  acidophilus  is  very 
frequently  the  more  prominent. 

The  fermentative  action  is  increased  by  sodium  and 
potassium  salts  as  found  in  whey.  (This  latter  probably 
in  part  explains  the  results  obtained  in  feeding  malt 
sugars  together  with  potassium  carbonate.) 

Proteins  favor  the  development  of  the  organisms  of 
putrefaction  and  lead  to  formation  of  indol,  skatol,  and 
amino-acids,  these  being  the  products  of  aromatic  and 
fatty  series.  Gases  are  also  formed  by  the  latter  action. 

The  nature  of  the  protein  influences  the  types  of  pro- 
teolytic  bacteria  to  a  very  marked  degree.  In  general, 
animal  proteins  other  than  casein  appear  to  encourage 
somewhat  more  active  proteolytic  flora  than  vegetable 
proteins.  The  processes  of  'putrefaction  are  favored  by 
calcium  salts. 

The  influence  of  fat  in  its  relation  to  bacterial  proc- 
esses is  not  clear.  It  seems  to  be  able  to  favor  fermenta- 
tion, if  this  be  already  present,  and  also  to  increase  the 
intensity  of  the  processes  of  putrefaction. 

In  breast  feeding  fermentation  outweighs  putrefaction. 
The  question  whether  fermentation  or  putrefaction  in 
the  intestinal  canal  is  desirable,  must  be  answered  a  priori 
that  the  fermentative  processes  are  physiological,  since 


32  INFANT   FEEDING. 

breast  feeding  always  leads  to  this.  By  this  it  must  not 
be  understood  that  the  putrefaction  in  artificial  feeding 
causes  injury.  Excessive  intestinal  fermentation  in  ar- 
tificial feeding  may  be  the  forerunner  of  disaster,  and  is 
to  be  avoided  (dyspepsia,  intoxication). 

Within  certain  limits,  we  are  able  to  influence  the  bac- 
terial processes  in  the  intestinal  tract  in  the  normal  infant, 
and  thereby  change  the  character  of  the  feces.  In  a  sick 
infant  this  is  more  difficult,  and  larger  quantities  of 
putrefacient  food  are  necessary  to  overcome  pathological 
fermentation. 

6.  Intestinal  Bacteria  in  Their  Relation  to  Gastro- 
intestinal Disturbances. 

There  are  many  intestinal  disturbances  of  unknown 
causation,  presumably  unrelated  to  bacterial  activity. 
There  is  a  second  group  of  conditions  in  which  bacteria 
may  conceivably  play  a  secondary  part;  in  some  of  the 
latter  abnormal  physiological  conditions  in  the  alimentary 
canal  may  be  justly  regarded  as  the  antecedent  factors. 
The  boundaries  of  these  two  groups  are  poorly  circum- 
scribed, and  they  merge  through  imperceptible  or  poorly 
defined  limits  into  a  third  group  of  cases  in  which  the 
activities  of  endogenous  or  exogenous  bacteria  in  the 
alimentary  canal  may  be  the  causative  factor  in  morbid 
processes  of  the  gastro-intestinal  tract. 

The  symptomatology  induced  from  the  products  aris- 
ing from  the  decomposition  of  proteins  or  protein  deriva- 
tives by  the  action  of  bacteria  in  the  intestinal  tract  de- 
pends largely  upon  the  organism  or  organisms  concerned. 
It  varies  from  the  somewhat  insidious,  slowly  progress- 
ing, so-called  autointoxication,  in  which  a  marked  in- 
crease of  urinary  ethereal  sulphates  may  be  a  suggestive 
index,  to  the  acute  toxemias  characteristic  of  bacillary 
dysentery,  typhoid,  paratyphoid  or  cholera.  Of  course, 
a  variety  of  other  bacteria  than  the  few  mentioned  speci- 
fically may  be  concerned,  either  alone  or  in  symbiosis. 


BACTERIA    OF   THE    DIGESTIVE   TRACT.          33 

Thus  streptococci  alone,  and  streptococci  in  association 
with  dysentery  bacilli,  may  be  justly  regarded  as  the  etiol- 
ogical  agents  in  their  respective  syndromes.  The  im- 
portant factor,  from  the  viewpoint  of  this  discussion,  is 
to  realize  that  the  formation  of  nitrogenous  products 
from  proteins  or  protein  derivatives,  which  are  being 
utilized  by  various  types  of  intestinal  bacteria  for 
energy,  may  be  injurious  to  the  host. 

The  other  prominent  type  of  abnormal  bacterial  activ- 
ity in  the  alimentary  canal — the  fermentative  type — is  of 
entirely  different  origin.  The  essential  factor  is  either 
a  fermentation  of  carbohydrates,  with  the  formation  of 
products  abnormal  for  the  intestine,  or  of  excess  of  nor- 
mal fermentative  products.  The  factors  leading  to  an 
overgrowth  of  these  organisms  in  the  intestinal  tract 
appear  to  be  an  excess  of  carbohydrate  and  a  lack  of 
normal  lactic-acid-forming  bacteria. 

It  is  unfortunate  that  practically  none  of  the  bacteria 
which  incite  intestinal  disturbances  or  illnesses  produce 
soluble  toxins  against  which  antitoxins  can  be  prepared. 
Sera  likewise  have  been  unsatisfactory.  There  is  little, 
therefore,  that  can  be  accomplished  serologically  with  the 
present  methods  in  the  treatment  of  intestinal  disturb- 
ances of  bacterial  causation.  Attempts  to  permanently 
eliminate  or  destroy  undesirable  bacteria  with  cathartics 
and  intestinal  antiseptics  have  not  been  productive  of  re- 
sults in  the  past,  and  prolonged  starvation  per  se  does  not 
lead  to  intestinal  sterility  or  to  a  significant  reduction  in 
the  offending  bacteria. 

There  are  two  ways,  however,  in- which  direct  influ- 
ence may  be  applied  to  bacteria  in  the  intestinal  tract: 
by  substituting  harmless  types  of  organisms  for  abnormal 
types,  and  so  varying  the  diet  for  space  that  the  intestinal 
contents  at  the  desired  level  shall  contain  nutritive  sub- 
stances that  may  be  reasonably  expected  to  shift  the  me- 
tabolism of  the  offending  organism,  and  therefore  radic- 
ally change  the  character  of  the  products  of  its  metabolism. 

3 


34  INFANT   FEEDING. 

Diseases  Due  to  Proteolytic  Activity  of  Bacteria. 
There  are  a  number  of  conditions  of  bacterial  causation 
in  which  available  evidence  points  strongly  to  the  forma- 
tion of  products  arising  from  the  metabolism  of  protein 
or  protein  derivatives  by  specific  organism  as  important 
etiological  factors  in  the  morbid  process.  Thus,  cholera, 
bacillary  dysentery,  typhoid,  paratyphoid,  and  many  less 
acute  infections  are  associated  definitely  with  the  de- 
velopment of  these  organisms  within  the  body,  and  to 
some  degree  at  least,  at  the  expense  of  the  body  tissues. 

Available  evidence  points  strongly  to  the  view  that 
cholera  vibrios,  typhoid,  dysentery  and  paratyphoid  bacilli 
and  similar  organisms  produce  their  characteristic  and 
harmful  effects  when  they  are  developing  in  media  free 
from  utilizable  carbohydrates;  when  utilizable  carbohy- 
drates are  added  to  these  media,  non-characteristic,  harm- 
less products  are  formed. 

In  the  absence  of  any  definite  indication  to  the  con- 
trary, it  would  be  logical  to  attempt  to  maintain  a  suffi- 
cient concentration  of  carbohydrates  within  the  intestinal 
canal  in  these  infections  as  a  therapeutic  measure. 

The  important  effects  to  be  accomplished  by  a  liberal 
carbohydrate  diet  in  those  infections  where  the  decom- 
position of  proteins  or  protein  derivatives  by  bacterial 
activity  leads  to  chronic  or  acute  illness  of  intestinal 
origin  are :  a  change  in  the  metabolism  of  the  offending 
organism  resulting  in  the  formation  of  lactic  and  other 
acids  in  them  in  place  of  putrefactive  products,  and  a 
gradual  replacement  of  the  proteolytic  and  pathogenic 
types  by  bacteria  of  the  fermentative  varieties. 

Diseases  Due  to  Excessive  Fermentation  of  Carbohy- 
drates. Another  type  of  intestinal  disturbances  depends 
upon  an  unusual  or  an  excessive  fermentation  of  carbo- 
hydrates. This  is  frequently  seen  in  young  infants,  in 
many  of  whom  we  have  a  limited  carbohydrate  tolerance. 
(See  Nutritional  Disturbances.) 


PART  II. 

The   Nursing. 


CHAPTER   I. 

GENERAL  CONSIDERATIONS. 

WRITERS  on  this  subject  are  very  prone  to  state  that 
the  ability  of  the  mother,  particularly  among  the  well-to- 
do,  to  fulfil  this  most  important  function  is  decreasing. 
/This  may  have  been  a  true  statement  fifteen  or  twenty 
years  ago.    At  the  present  time,  however,  we  are  sure  it 
jl  is  erroneous.    The  young  mother  of  to-day  is  better  able 
A  to  nurse  her  offspring  than  was  her  sister  fifteen   or 
twenty  years  ago.    We  attribute  this  to  the  fact  that  the 
I  youth  of  the  present  day  are  more  vigorous,  more  nearly 
normal  individuals,  than  were  those  of  an  earlier  date. 
Breast-milk  during  the  first  two_or  three  weeks  of  the 
infant's  life  js_  produced  under  unfavorable  conditions, 
which  do  not  indicate  the  possibilities  of  t-hp 


^ecreting__organ.  Early  nursing,  following  as  it  does 
uporPthe  stress  of  confinement,  is  not  indicative  of  what 
may  be  possible  later,  when  the  customary  life  and  daily 
habits  are  resumed.  Repeatedly  we  have  found  a  very 
high  fat  or  a  high  protein,  or  both,  entirely  corrected 
after  the  first  week,  or  two,  without  interference.  This 
condition  at  the  time  was  considered  sufficiently  serious 
to  warrant  the  discontinuance  of  nursing  on  the  part  of 
a  weakly  infant,  while  in  a  vigorous  infant  it  would  be 
entirely  ignored.  A  neurotic  mother  makes  the  poorest 
possible  milk-producer.  Proportionate  to  the  popula- 
tion, there  are  fewer  neurasthenics  among  the  young 
women  to-day  than  there  were  twenty  years  ago,  and 

(35) 


36  INFANT   FEEDING. 

there  will  be  still  fewer  twenty  years  hence.  At  the 
present  time  the  timid,  retiring  young  woman  of  the 
neurasthenic  type  is  not  popular  in  her  set. 

Few  functions  with  which  we  have  to  deal  are  so 
variable  and  uncertain  as  the  production  of  breast  milk. 
Breast  milk  is  one  of  the  most  precious  substances.  It 
/  is  invaluable,  unless  we  can  put  value  on  human  life.|t 
The  most  successful  nursing  age  is  between  the  twentieth 
and  thirty-fifth  year. 

Some  mothers  will  be  able  to  carry  on  the  nursing  for 
only  two  months,  others  three,  five,  seven,  or  nine 
months.  In  our  experience  in  both  out-patient  and  in 
private  practice  it  is  extremely  rare  for  the  breast  milk 
to  be  sufficient  for  the  infant  after  the  ninth  month. 

It  should  be  remembered  that  besides  the  protein,  fat, 

carbohydrate,  salts  and  water  content  there  are  other 

bodies  contained  in  human  milk,  which,  even  though  not 

essential  to  the  infant's  life,  are  of  inestimable  value 

"to  it.    These  may  be  divided  into  two  groups: 

1.  Immunizing     bodies — antitoxins,      alexins,      etc. — 
which  are  contained  in  the  mother's  blood,  and  trans- 
mitted to  the  baby  through  her  milk.    They  are  of  value 
in  protecting  the  infant  against  infections. 

2.  Ferments:    lipase,  galactase,  lactokinase,  and  dias- 
tase. 

Examination  of  Human  Milk.  This  is  rarely  of  any 
practical  value.  The  protein  rarely  causes  trouble,  and 
the  sugar  is  usually  constant  (6  to  7  per  cent.).  The 
examination  of  milk  is  therefore  usually  restricted  to  a 
determination  of  the  fat  content  by  means  of  the  lacto- 
meter. -The  richest  milk,  however,  will  usually  agree 
with  the  baby,  and  it  is  apt  to  thrive  equally  well  on  a 
milk  that  shows  a  small  amount  of  fat.  In  other  words, 
the  baby  and  not  the  lactometer  is  the  only  practical  test. 
If  the  milk  disagrees,  it  will  be  evident  clinically.  No 
baby  should  ever  be  deprived  of  its  mother's  milk  only 


GENERAL  CONSIDERATIONS.  37 

because  of  the  results  of  a  clinical  examination  of  the 
milk. 

In  making  an  examination  of  the  mother's  milk  one 
must  bear  in  mind  that  the  first  milk  is  very  poor,  the 
last  very  rich  in  fat,  and  that  an  average  specimen  can 
be  obtained  only  by  mixing  the  whole  amount,  or  by 
combining  the  first  and  the  last,  or,  better  still,  by  taking 
only  the  middle  portion  after  a  few  drams  have  been 
drawn  off.  This  can  be  accomplished  by  allowing  the  in- 
fant to  nurse  for  two  minutes  before  expressing  the 
sample. 

Contraindications  to  Nursing.  Tuberculosis  when 
progressive  or  open  is  always  a  contraindication  to  nurs- 
ing, because  of  the  danger  to  the  infant  and  the  strain  on 
the  mother.  With  proper  precautions,  and  where  the 
breast  is  not  diseased,  and  human  milk  is  not  obtainable 
from  other  sources,  it  may  be  well  to  tide  a  weak  infant 
over  its  first  weeks  by  expressing  the  milk  from  the 
mother's  breast. 

Syphilis  of  the  mother,  except  in  freedom  from  infec- 
tion on  the  part  of  the  infant,  is  not  a  contraindication. 
Lack  of  symptoms  on  the  part  of  the  mother  in  congeni- 
tal syphilis  is  a  very  common  occurrence ;  a  Wassermann 
reaction  on  the  mother's  blood  will  quickly  clear  up  any 
doubt. 

Any  grave  constitutional  disease  in  which  there  is  an 
extraordinary  drain  on  the  resources  of  the  body  (dia- 
betes, heart  disease  with  disturbed  compensation,  neph- 
ritis, Basedow's  disease,  malignant  neoplasms,  epilepsy 
and  psychoses)  are  contraindications  to  nursing. 

Acute  diseases  should  only  in  exceptional  cases  be  con- 
sidered as  contraindications  to  nursing,  and  should  in- 
clude conditions  in  which  there  is  danger  of  overburden- 
ing the  mother  and  infections  endangering  the  infant. 
(See  p.  65  for  further  indications.) 


CHAPTER    II. 
MATERNAL   NURSING. 

1.  Nursing  Axioms. 

The  following  may  be  laid  down  as  nursing  axioms : 

A  diet  similar  to  what  the  mother  was  accustomed  to 
before  the  advent  of  motherhood  can  usually  be  taken. 

There  should  be  one  bowel  evacuation  daily. 

From  three  to  four  hours  daily  should  be  spent  in  the 
open  air  in  exercise  which  does  not  fatigue. 

At  least  eight  hours  out  of  every  twenty-four  should 
be  given  to  sleep. 

There  should  be  absolute  regularity  in  nursing  and 
expression. 

There  should  be  no  worry  and  no  excitement. 

The  mother  should  be  temperate  in  all  things. 

2.  Hygiene  of  the  Mother. 

The  Diet  of  the  Mother.  Many  times,  when  con- 
sulted by  nursing  mothers  because  the  nursing  was  un- 
successful or  a  partial  failure,  we  have  found  that  their 
diet  had  been  restricted  to  an  extreme  degree.  To  put 
on  a  greatly  restricted  diet  a  robust  young  mother  who 
has  always  eaten  bountifully  of  a  generous  variety  of 
foods  is  one  of  the  best  means  of  curtailing  the  quantity 
and  lowering  the  quality  of  her  milk  supply.  When 
asked  to  prescribe  a  diet,  we  tell  such  mothers  to  eat  as 
they  were  accustomed  to  before  the  advent  of  pregnancy 
and  motherhood.  That  this  particular  vegetable  or  that 
particular  fruit  should  be  forbidden  on  general  prin- 
ciples is  a  fallacy.  Food  that  the  patient  can  digest  with- 
out inconvenience  is  a  safe  food  so  far  as  the  nursing  is 
concerned,  as  may  readily  be  determined  in  any  given 
case.  For  certain  individuals,  however,  a  plain,  more  or 
(38) 


MATERNAL   NURSING.  39 

less  restricted  diet  is  desirable.  This  must  be  enforced  in 
the  management  of  the  wet-nurse  (to  be  detailed  later). 

Nursing  is  a  perfectly  normal  function,  and  a  woman 
should  be  permitted  to  carry  it  out  along  the  natural 
lines.  Inasmuch  as  there  are  two  lives  to  be  provided 
for  instead  of  one,  more  food,  particularly  of  a  liquid 
character,  may  be  taken  than  the  mother  may  be  accus- 
tomed to.  It  is  our  custom  to  advise  that  milk  be  given 
freely.  A  glass  of  milk  may  be  taken  in  the  middle  of 
the  afternoon,  and  8  ounces  of  milk  with  8  ounces  of 
oatmeal  or  cornmeal  gruel  at  bedtime,  if  it  does  not  dis- 
agree with  the  mother.  Our  only  evidence  that  a  food  is 
disagreeing  is  the  condition  of  the  digestion.  When 
any  article  of  food  disagrees  with  the  mother,  or  if  she 
is  convinced  that  it  disagrees,  whether  or  not  such  be 
really  the  case,  the  food  should  be  discontinued.  In  a 
general  way,  milk  (one  quart  daily),  eggs,  meat,  fish, 
poultry,  cereals,  fresh  vegetables  and  fruits  constitute  a 
basis  for  selection.  Although  occasionally  a  nursing 
mother  cannot  take  acid  fruits,  salads  and  aromatic  vege- 
tables, they  may  be  tried  and  discarded,  if  they  disturb 
the  infant.  Eggnogs,  thin  cereal  gruels  mixed  with  milk, 
cocoa  and  malted  milk  and  similar  drinks  can  often  be 
taken  to  advantage  between  meals. 

The  Bowel  Function.  A  very  important  and  often 
neglected  matter  in  relation  to  nursing  is  the  condition 
of  the  bowels.  There  must  be  one  free  evacuation  daily. 
For  the  treatment  of  constipation  in  nursing  women  we 
have  used  different  methods  in  many  cases.  The  dietetic 
treatment  and  plenty  of  recreation  and  exercise  promise 
most.  Manipulation  of  the  diet  should  not  be  such  as 
to  interfere  with  the  milk  production.  Three  other 
methods  are  open  to  use:  massage,  local  measures  and 
drugs.  Massage  is  available  in  comparatively  few  cases. 
Local  measures  consist  in  the  use  of  enemas  and  sup- 
positories. Every  nursing  woman  under  our  care  is  in- 
structed to  use  an  enema  at  bedtime,  if  no  evacuation  of 


40  INFANT   FEEDING. 

the  bowels  has  taken  place  during  the  previous  twenty- 
four  hours.  For  a  laxative  in  such  cases  and  in  many 
others,  a  capsule  of  the  following  composition  has  served 
well: 

IJ  Extract!  nucis  vomicae 0.015  Gm.  (J4  gr.). 

Extracti  cascarae  sagradae 0.325  Gm.  (v  gr.) . 

Sig. :    To  be  taken  at  bedtime. 

The  amount  of  the  cascara  sagrada  may  be  varied  as 
the  case  may  require.  In  not  a  few  instances  we  have 
found  it  necessary  to  give  2  capsules  a  day  in  order  "to 
produce  the  desired  result.  Neither  the  nux  vomica  nor 
the  cascara  appears  to-  have  any  appreciable  effect  on  the 
child. 

Air  and  Exercise.  Outdoor  life  and  exercise  are  not 
only  as  desirable  here  as  they  are  under  all  other  con- 
ditions, but  to  the  nursing  woman,  with  her  added  re- 
sponsibility, they  are  doubly  valuable.  In  order  to  get 
the  best  results,  exercise  or  work  should  be  so  adjusted 
as  not  to  reach  the  point  of  fatigue.  The  mother  whose 
nights  are  disturbed  should  be  given  the  benefit  of  a 
midday  rest  of  an  hour  or  two.  It  should  be  our  duty, 
however,  to  explain  to  the  mother  and  to  other  members 
of  the  family  that  an  important  element  in  satisfactory 
nursing  is  a  tranquil  mind. 

Care  of  the  Breasts.  A  well  established  routine  should 
be  instituted  for  the  care  of  the  breasts.  To  facilitate 
this  a  readily  accessible  tray  with  the  necessary  utensils 
should  be  provided.  This  should  contain  a  glass-stop- 
pered bottle  with  a  saturated  solution  of  boric  acid,  a 
jar  of  cotton  pledgets  on  toothpicks,  to  be  used  as  appli- 
cators for  the  boric  acid,  a  graduated  glass  or  beaker. 
The  nipples  should  be  thoroughly  washed  before  and 
after  nursing  with  a  saturated  solution  of  boric  acid 
poured  fresh  from  the  bottle  for  each  cleansing,  and  the 
surplus  thrown  away.  The  boric  acid  should  be  applied 
with  the  cotton  pledgets.  The  fingers  should  not  come 


MATERNAL   NURSING.  41 

in  contact  with  the  nipples,  if  the  child  is  to  nurse  directly 
at  the  breast.  If  the  nipples  are  tender,  they  should  be 
anointed  with  a  sterile  mixture  of  5  per  cent,  tincture 
of  benzoin  in  liquid  vaseline. 

All  utensils,  including  the  breast-pump,  if  one  is  in 
use,  should  be  sterilized  by  boiling.  In  case  of  the  breast- 
pump,  the  rubber  bulb  may  be  removed  for  this  purpose. 
Where  the  milk  is  to  be  expressed  by  hand,  the  hands 
must  be  thoroughly  disinfected  by  washing  with  soap 
and  water,  and  rinsing  with  alcohol  before  manipulation 
of  the  breasts.  Under  all  conditions  soap  and  water 
should  be  freely  accessible,  and  their  use  required  before 
handling  the  breast  or  the  infant. 

3.  Conditions  Influencing  the  Breast  Milk. 

The  advent  of  the  first  menstruation  period  particu- 
larly, and  in  some  cases  the  beginning  of  every  men- 
struation period,  is  attended  with  an  attack  of  colic  or 
indigestion  in  the  child.  Such  attacks,  however,  rarely 
necessitate  the  discontinuance  of  the  nursing  even  for 
a  single  day.  Not  infrequently  the  quantity  of  milk  is 
somewhat  lessened  during  menstruation,  and  this  will  re- 
sult in  the  infant  becoming  fretful,  due  to  insufficient 
quantity  of  the  feeding.  Under  no  circumstances  should 
menstruation  be  considered  an  indication  for  weaning. 

Factors  influencing  the  mental  condition  of  the  mother, 
such  as  anger,  fright,  worry,  shock,  distress,  sorrow,  or 
the  witnessing  of  an  accident  may  affect  the  milk  secre- 
tion sufficiently  to  cause  no  little  discomfort  to  the  child, 
and  oftentimes  the  lessening  of  the  flow  for  a  day  or 
two.  At  times,  especially  when  the  mother  is  under  in- 
fluence of  shock  or  grief,  it  may  be  necessary  to  substi- 
tute artificial  feeding  for  a  few  nursings  during  these 
periods,  until  the  mother  has  again  resumed  her  mental 
equilibrium,  her  breast  being  emptied  by  mechanical 
means  in  the  meantime. 


42  INFANT   FEEDING. 

Drugs,  alkaloids  of  opium,  hyoscyamus,  belladonna, 
and  similar  drugs,  when  given  in  large  quantities,  not  in- 
frequently pass  into  the  milk,  and  should  therefore  never 
be  administered  in  large  quantities  to  the  nursing  mother. 
Belladonna  may  cause  a  decrease  in  milk  secretion,  and 
should  be  administered  with  caution  during  the  period  of 
lactation.  Mercury,  iodides  and  the  newer  salts  of  ar- 
senic are  also  secreted  in  the  milk,  and  may  be  used  to 
advantage  when  a  luetic  mother  is  nursing  a  luetic  infant. 

4.  The  Nursing  Proper. 

Regularity  in  Nursing.  The  breast  which  is  emptied 
at  definite  intervals  invariably  functionates  better  than 
does  one  which  is  not,  not  only  as  regards  the  quantity, 
but  also  the  quality,  of  the  milk,  thus  regular  habits  in 
breast-feeding  are  as  essential  to  milk  production  as  to 
its  digestion  and  assimilation.  The  baby  should  be 
wakened  to  be  fed. 

The  average  mother  will  supply  the  needs  of  the  in- 
dividual meal  with  one  breast,  and  the  breasts  should  be 
alternated  in  successive  feedings.  Thorough  emptying 
of  the  breast  should  be  encouraged  under  all  circum- 
stances, as  this  is  our  best  method  for  increasing  the 
milk  supply,  and  the  baby  is  the  only  means  at  hand  by 
which  this  can  be  accomplished.  This  should  be  en- 
couraged in  every  instance.  It  is  most  readily  thwarted 
by  allowing  a  lazy  baby  to  partially  empty  both  breasts, 
and  will  soon  lead  to  a  diminished  milk  secretion.  By 
this  means  the  mother  and  the  baby  soon  become  adapted 
to  one  another,  and  it  will  be  found  that  the  desired  effect 
is  accomplished  both  where  the  milk  supply  is  insuffi- 
cient or,  again,  excessive.  In  the  former  instance  com- 
plete emptying  of  the  breasts  increases  the  secretion,  and, 
where  excessive,  incomplete  emptying  will  soon  result  in 
a  lessened  supply. 

Sometimes,  however,  it  is  advisable  to  give  both  breasts 
at  each  feeding,  i.e.,  under  the  following  conditions :  ( 1 ) 


MATERNAL    NURSING.  43 

During  the  first  few  days,  to  stimulate  secretion,  and  a 
little  later  to  relieve  the  congested  breasts;  (2)  to  weak 
babies  when  there  is  an  abundance  of  milk,  and  they  are 
not  strong  enough  to  get  the  last  milk  that  comes  harder ; 
(3)  to  overfed  babies,  where  it  is  desirable  to  give  them 
only  the  first  and  weakest  milk,  and  to  lessen  the  yield 
of  the  milk  from  the  breast ;  (4)  as  the  milk  supplied  by 
one  breast  fails  to  meet  the  needs  of  the  infant,  both 
breasts  should  be  given  at  each  nursing;  the  first  breast 
should  be  thoroughly  emptied  before  allowing  the  baby 
to  take  the  second  breast,  and  the  next  nursing  started 
on  the  second  breast  given  in  the  last  feeding. 

Number  of  Feedings  in  Twenty-four  Hours.  Four- 
hour  intervals  at  start  with  six  feedings  in  twenty-four 
hours,  five  feedings  by  the  second  to  the  fifth  month,  ac- 
cording to  the  individual  needs  of  the  child.  Night 
nursing  can  often  be  discontinued  by  this  time,  and 
babies  properly  fed  will  go  from  10  P.M.  to  6  A.M.  with- 
out anything  but  perhaps  a  drink  of  water. 

Premature  and  delicate  infants  and  infants  with  a 
tendency  to  vomit  are  exceptions,  and  must  be  fed  smaller 
amounts  at  more  frequent  intervals. 

Length  of  Nursing.  As  a  rule  a  robust  baby  takes 
three-fourths  of  the  milk  obtained  from  a  good  breast 
in  the  first  five  minutes  of  a  twenty-minute  nursing. 
Fifteen  to  twenty  minutes  should  be  the  limit  for  the 
nursing  period. 

The  quantity  received  at  individual  nursings  will  vary 
greatly  throughout  the  day.  The  early  morning  nursings 
will  often  yield  twice  the  amount  of  the  later  nursings. 
Therefore  it  is  necessary  to  ascertain  the  twenty-four 
hour  quantity  in  order  to  estimate  the  total  value  of  milk 
received. 

When  one  breast  does  not  meet  the  infant's  demands 
both  breasts  should  be  given  at  each  feeding,  the  normal 
nursing  time  of  fifteen  or  twenty  minutes  being  divided 
between  the  two  breasts,  either  equally  or  by  alternating 


44  INFANT   FEEDING. 

a  long  and  short  feeding  period  of  fifteen  and  five  min- 
utes, so  that  each  breast  will  receive  a  long  nursing  period 
at  alternate  feedings.  Weak  and  lazy  babies  may  require 
awakening  during  the  nursing  period  to  keep  them  at 
work.  Very  weak  babies  may  require  a  longer  period 
with  short  intervals  in  which  they  rest. 

The  Daily  Total  of  Milk  Required.  Most  young  in- 
fants will  satisfy  their  requirements  for  growth  and  de- 
velopment when  receiving  an  average  of  two  and  one- 
half  ounces  (75  mils)  of  human  milk  per  pound  (i/> 
kilo.)  body  weight,  in  twenty-four  hours.  Roughly  this 
may  be  stated  as  one-sixth  of  the  body  weight  in  milk 
daily  (50  calories  per  pound).  Older  infants  will  usu- 
ally thrive  on  two  ounces  (60  mils)  or  40  calories  of 
breast  milk  per  pound  or  one-eighth  of  their  weight. 

While  infants  of  the  same  weight  and  age  under  the 
same  conditions  will  require  practically  the  same  amounts 
to  provide  for  growth  and  development,  on  the  whole  the 
fat  baby  will  require  less  per  pound  than  the  thin  one. 

Water  Requirements.  When  the  infant  is  receiving 
one-sixth  of  its  body  weight  in  milk  during  the  day,  little, 
if  any  additional  water  is  required.  When  the  breast- 
milk  does  not  meet  this  requirement  additional  water  or 
other  food  must  be  administered  to  meet  the  required 
one-sixth  of  the  body  weight  in  fluids.  During  the  first 
days  of  life,  when  the  breast  milk  supply  is  insufficient, 
total  fluids  should  be  administered  to  meet  the  above 
needs.  From  one  to  three  ounces  of  a  2  to  5  per  cent, 
solution  of  cane  or  milk  sugar  which  has  been  boiled, 
may  be  given  to  the  infant  at  twenty-four  hour  intervals 
until  the  milk  appears. 

Before  giving  the  water,  the  infant  should  be  placed 
at  the  breast  at  each  feeding.  Even  when  milk  is  plen- 
tiful the  administration  of  water  two  or  three  times  daily 
from  a  nursing  bottle  accustoms  the  infant  to  taking  the 
food  in  this  way.  An  infant  so  trained  will  meet  emer- 


MATERNAL   NURSING.  45 

gencies  of  weaning  more  readily  than  one  unaccustomed 
to  bottle  feeding. 

Feeding  During  the  First  Days.  During  the  first 
day  of  life,  food  may  be  withheld  for  twelve  hours,  the 
infant  being  kept  in  a  warm  crib.  It  usually  soon  falls 
asleep,  and  as  a  rule  it  should  be  awakened  only  to 
change  diapers.  As  a  rule  the  child  does  not  evidence 
its  initial  sensation  of  hunger  by  crying  until  after  its  first 
half  day  of  life,  and  even  then  in  many  cases  it  is  dif- 
ficult to  obtain  the  co-operation  of  the  infant  in  adminis- 
tering its  food.  During  the  second  twelve  hours  the 
infant  may  be  put  to  the  breast  two  or  three  times  in 
order  to  stimulate  secretion  and  to  teach  it  to  nurse. 
During  the  second  twenty-four  hours  the  baby  should  be 
put  to  the  breast  at  regular  four-hour  intervals.  The 
sixth  feeding  may  be  omitted.  By  the  third  or  fourth 
day  the  infant  will  usually  receive  most  of  its  required 
food  from  the  breast.  If  a  night  feeding  is  to  be  insti- 
tuted it  is  well  to  waken  the  baby  at  the  regular  hour  in 
order  to  cultivate  regular  habits,  which  are  so  essential 
to  the  mother's  welfare. 

The  Total  Nursing  Period.  Some  mothers  will  be 
able  to  carry  on  the  nursing  for  only  two  or  three  months, 
others  as  long  as  nine  months.  In  out-patients  as  well 
as  in  private  practice,  it  is  exceptional  to  find  a  breast- 
milk  supply  which  is  sufficient  for  the  infant  after  the 
ninth  month.  It  is  usually  wise  to  allow  one  bottle  feed- 
ing daily,  by  the  end  of  the  third  or  fourth  month,  in 
order  to  relieve  the  mother,  and  at  the  same  time  train 
the  baby  in  bottle  feeding. 


CHAPTER    III. 
WET-NURSING. 

1.  The  Wet-nurse:    Her  Selection  and  Her  Baby. 

The  Problem.  When  there  is  a  positive  inability  on  the 
part  of  the  mother  to  nurse  her  offspring,  either  through 
inadequate  functioning  on  the  part  of  the  breast  or  sys- 
temic disease,  we  are  confronted  with  the  problem  of 
securing  human  milk  from  another  source,  as  notwith- 
standing the  numerous  isolated  reports  on  successful 
raising  of  infants  on  artificial  foods,  the  statistics  of  in- 
fants fed  by  artificial  foods  when  compared  with  those 
of  infants  fed  on  human  milk  are  so  strikingly  in  favor 
of  the  latter  that  the  obtaining  of  human  milk  must  al- 
ways be  considered  as  an  important  issue. 

How  Obtained.  In  our  experience,  even  in  a  large 
city,  great  difficulty  has  been  met  in  obtaining  a  regular 
supply  of  wet-nurses.  On  several  occasions  various 
charitable  and  hospital  societies  have  attempted  to  estab- 
lish a  wet-nurses'  registry  as  a  clearing-house  for  the 
several  maternity  and  general  hospitals  of  Chicago. 
These  attempts  have  not  been  successful  for  two  reasons : 
(1)  because  of  the  irregularity  in  the  demand,  and  (2) 
because  of  the  lack  of  co-operation  on  the  part  of  the 
various  institutions  caring  for  this  class  of  cases. 

The  Nationality  of  the  Wet-nurse  is  of  considerable 
significance  where  the  supply  allows  of  a  selection.  The 
phlegmatic  temperaments  as  seen  in  women  of  Northern 
and  Central  Europe  of  Teutonic  and  Slavic  descent, 
offer  the  ideal  material,  while  other  nationalities,  such  as 
Italians,  and  the  Southern  negroes  when  removed  from 
their  home  environment  to  a  Northern  climate,  with  the 
consequent  change  in  diet,  secrete  a  milk  poor  in  quality. 
(46) 


WET-NURSING.  47 

However,  even  the  latter  in  an  emergency  should  not  be 
neglected. 

Requirements  of  a  Good  Wet-nurse.  1.  She  should 
be  in  good  health,  and,  especially,  free  from  all  con- 
tagious and  infectious  diseases,  and  also  from  local 
diseases  of  any  kind,  such  as  those  involving  the  nose, 
throat,  skin,  etc. 

2.  Her  mammary  glands  should  be  of  such  quality  that 
she  can  secrete  sufficient  milk  of  good  quality,  and  the 
nipples   sufficiently   developed  to  allow   of   nursing,   or 
proper  expression  of  the  milk. 

3.  Whenever  possible,  her  age  should  be  not  less  than 
18  and  not  more  than  35  years. 

4.  The  age  of  her  baby,  as  compared  with  that  of  the 
baby  she  is  to  nurse,  is  a  matter  of  indifference  in  most 
instances.     However,  the  first  weeks,  or  if  possible  the 
first  two  months,  of  lactation  should  be  avoided,  because 
of  the  presence  of  colostrum  and  the  rapidly  changing 
quality  of  the  breast  milk,  which  not  infrequently  causes 
serious  gastric  and  intestinal  disturbances  in  very  suscep- 
tible infants,  as  evidenced  by  vomiting,  colic  and  diar- 
rhea.    Multiparity  may  be  considered  an  asset,  if  the 
nurse  has  demonstrated  her  .ability  to  care  for  and  feed 
previous  cases.     A  multipara  is  also  less  likely  to  be 
affected  by  her  new  surroundings,  especially  if  this  be  a 
private  home.     When  the  wet-nurse  has  more  or  less 
direct  charge  of  the  infant,  one  who  has  been  nursing 
her  own  or  other  infants  will  be  more  likely  to  meet  the 
technical  difficulties  in  the  care  of  her  charge. 

Examination  of  the  Wet-nurse.  The  examination  of 
the  wet-nurse  should  always  be  made  in  a  systematic 
manner  to  insure  against  overlooking  important  things. 

First,  a  careful  history  should  be  taken  as  to  the  num- 
ber of  her  children,  miscarriages,  and  the  presence  of 
constitutional  diseases  in  her  family. 

Second,  she  should  be  thoroughly  examined,  all  parts 
of  the  body  being  exposed,  and  the  examination  should 


48  INFANT   FEEDING. 

include  the  skin  and  hairy  parts  of  the  body  for  the  pres- 
ence of  skin  lesions  and  parasites,  as  well  as  for  old 
luetic  scars.  The  organs  of  the  chest  and  abdomen 
should  be  subjected  to  careful  examination. 

Third,  the  breasts  should  be  examined. 

Fourth,  the  genitalia,  including  the  cervix  and  the 
urethra,  and  in  all  cases  a  cervical  (and  where  sus- 
picious, a  urethral)  smear  should  be  taken  and  exam- 
ined for  gonococci.  As  a  single  smear  is  often  mislead- 
ing, in  cases  of  the  slightest  suspicion,  where  a  girl  baby 
is  to  be  nursed,  the  examination  of  the  cervical  and 
urethral  smears  should  be  repeated. 

Fifth,  an  examination  and  search  should  be  made  for 
chronic  infections,  especially  for  syphilis.  A  Wasser- 
mann  test  should  be  made  in  every  case,  and  reported 
upon  before  she  is  allowed  to  supply  milk,  as  it  is  well 
known  that  a  syphilitic  mother  in  a  very  great  number  of 
cases  shows  no  clinical  evidence  of  syphilis.  The 
mouth  and  pharynx,  neck,  anus  and  genitalia,  entire  skin 
and  lymphatic  glands  should  also  be  examined  for  evi- 
dence of  syphilitic  lesions. 

Tuberculosis.  The  lungs,  glands,  and  osseous  system 
should  be  examined,  and  a  careful  history  as  to  suscep- 
tibiHty  to  colds  and  to  recurring  bronchitis  elicited. 

Sixth.  Acute  infections.  She  should  be  questioned  as 
to  exposure  to  contagious  disease,  and  she  should  be  ex- 
amined for  evidence  of  acute  infections  of  the  nose, 
throat,  and  ears. 

Seventh.  Her  teeth  should  be  examined  and  defects 
and  pyorrhea  corrected,  if  necessary,  at  the  expense  of 
the  family. 

Eighth.  The  urine  should  be  examined  (1)  for  evi- 
dence of  nephritis,  (2)  for  evidence  of  diabetes.  It 
should,  however,  be  remembered  that  a  positive  reaction 
for  sugar  should  not  be  overestimated,  unless  the  sugar 
is  proven  to  be  dextrose,  as  very  commonly  in  our  ex- 
perience during  the  early  weeks  of  lactation  a  lactosuria 


WET-NURSING.  49 

is  present.  The  kind  of  sugar  can  easily  be  determined 
by  the  phenylhydrazine  test,  followed  by  a  microscopical 
examination  of  the  crystals. 

Ninth.  Nervous  and  psychic  disturbances,  such  as 
epilepsy,  insanity,  hysteria,  should  be  cause  for  rejection 
of  the  nurse. 

Tenth.  Her  child  should  be  examined  for  evidence  of 
syphilis.  Possibly  one  of  the  best  arguments  for  the 
non-employment  of  a  wet-nurse  during  the  first  two 
months  of  her  lactation  is  the  possibility  of  a  latent 
syphilis.  Where  there  is  the  slightest  doubt,  a  Wasser- 
mann  reaction  should  be  made  on  the  infant.  The  gen- 
eral condition  of  the  child  gives  us  the  best  evidence  both 
as  to  the  quantity  and  to  the  quality  of  the  maternal  milk. 
Unless  the  source  of  the  nurse  be  known,  it  is  well 
to  be  certain  that  she  is  nursing  her  own  baby.  In  case 
of  its  death  or  its  absence,  every  effort  should  be 
made  to  obtain  its  condition  at  birth  and  its  later 
development. 

So  far  as  possible  she  should  not  be  subjected  to  an- 
noying questioning  on  the  part  of  the  family,  which  is 
entirely  unnecessary,  if  she  has  been  properly  examined 
by  the  physician.  It  has  been  our  experience  that  such 
unnecessary  questioning  has  led  to  nervousness,  and  not 
infrequently  has  caused  her  to  decline  the  position,  at  a 
time  when  she  was  most  needed. 

Her  Place  in  the  Household.  She  should  be  treated 
neither  as  a  guest  nor  as  a  menial,  but  so  far  as  possible 
should  be  graded  according  to  her  previous  station  in 
life."  There  is  a  grave  danger  of  mental  depression  on  the 
part  of  a  woman,  well-born  and  sensitive,  who,  through 
misfortune  or  necessity,  is  forced  to  seek  this  means  of 
employment,  and  also  of  an  exaggerated  estimate  of 
self-importance  on  the  part  of  a  woman  but  little  accus- 
tomed to  the  luxuries  of  life  upon  her  entrance  into  the 
home  of  employment,  particularly  if  attentions  are  paid 
to  her.  As  has  been  previously  stated,  all  instructions 

4 


50  INFANT   FEEDING. 

and  demands  should  be  made  by  the  person  best  qualified 
in  the  individual  case.  A  divided  responsibility  will 
always  lead  to  future  complications. 

Her  quarters  should  be  well  located;  their  ventila- 
tion should  be  supervised,  and  she  should  be  held  re- 
sponsible for  their  general  cleanliness.  The  wet-nurse's 
baby  should  always  be  kept  in  the  room  with  her,  so  that 
she  may  feel  the  full  responsibility  for  its  health  and  care. 

The  Quantity  of  Milk  to  be  Expected  from  a  Good 
Wet-nurse.  The  quantity  and  quality  of  milk  supplied 
must  vary  greatly  with  the  glandular  development  of  the 
individual  wet-nurse,  .the  state  of  her  health,  and  the 
factors  quoted  elsewhere  which  would  affect  it  tempor- 
arily. The  amount  and  variety  of  stimulation  applied  to 
the  breasts,  of  which  the  direct  nursing  by  a  full-term 
infant  is  the  most  valuable  (at  least  for  the  purpose  of 
stripping  the  breasts),  must  be  given  due  consideration. 
In  view  of  the  many  emergencies  and  influencing  factors, 
no  absolute  standard  for  quantity  and  quality  can  be  set 
for  general  rule. 

A  wet-nurse  who  does  not  secrete  sufficient  milk  dur- 
ing the  first  few  days  in  her  new  employment  should  not 
be  discharged  until  every  effort  has  been  made  to  im- 
prove her  milk  production.  Frequently  the  change  in 
environment  is  sufficient  to  reduce  it  temporarily. 

Cost  of  Milk.  The  wet-nurses  in  Sarah  Morris  Hos- 
pital receive  their  board  and  room  and  $12.00  per  week. 
Figuring  the  former  at  $10.00  per  week,  this  would  total 
a  cost  to  the  institution  of  $22.00  per  week  for  each 
nurse.  With  an  average  of  30  to  40  ounces  of  milk  per 
nurse  daily,  or  210  to  300  ounces  per  week,  the  average 
cost  will  be  about  7  to  10  cents  per  ounce,  or  approxi- 
mately $2.25  to  $3.25  per  quart. 

When  milk  is  dispensed  to  patients  outside  of  the  hos- 
pital, a  charge  of  10  cents  an  ounce  is  made  for  it,  which 
is  a  reasonable  price  when  all  of  the  contending  factors 
are  taken  into  consideration. 


WET-NURSING.  51 

Number  of  Nurses  Needed.  Each  good  wet-nurse 
can  care  for  the  needs  of  about  two  infants,  depending 
upon  their  weight  and  development.  In  addition  her  own 
infant  can  often  be  satisfied  with  the  strippings.  When 
insufficient  her  baby  may  be  given  a  mixed  diet. 

Length  of  Lactation.  No  time-limit  is  placed  upon 
the  employment  of  a  wet-nurse  as  long  as  the  quality  and 
quantity  of  her  milk  is  sustained,  and  she  continues  in 
good  health.  One  of  our  nurses  had  an  infant  eighteen 
months  old.  Such  long  periods  of  lactation,  however,  as 
a  whole  are  not  to  be  advised. 

The  Wet-nurse's  Baby.  The  presence  of  the  wet- 
nurse's  baby  predisposes  to  her  peace  of  mind,  and 
wherever  possible,  she  should  take  it  with  her.  Her 
baby's  state  of  health  is  by  all  means  the  best  indication 
as  to  her  ability  as  a  nurse,  and,  with  this,  the  presence 
of  constitutional  disease  in  herself.  It  may  be  of  im- 
mense value,  if  the  baby  is  strong  and  healthy,  to  keep 
up  the  flow  of  milk,  in  case  the  baby  to  be  nursed  is  a 
weakling.  It  may  also  be  used  to  estimate  the  functional 
capacity  of  a  wet-nurse  by  nursing  at  regular  intervals, 
and  weighing  before  and  after  the  nursing  for  twenty- 
four-hour  periods.  If  in  perfect  health,  it  may  be  put  to 
the  breast,  after  the  weakling  has  taken  such  milk  as  it 
has  strength  to  draw.  If  this  is  not  practicable,  then  the 
weakling  should  be  nursed  alternately  with  the  well  baby 
on  each  breast.  It  is  also  of  immense  value  in  emptying 
the  breast  after  the  wet-nurse  has  removed  as  much 
milk  as  it  is  possible  by  expression  or  by  the  breast- 
pump,  if  this  is  the  means  of  drawing  the  milk  for  the 
weakling.  It  is  a  well-known  fact  in  all  institutions 
where  wet-nurses  are  used,  that  the  greater  the  degree 
to  which  the  breasts  are  stimulated  by  suckling  infants, 
the  greater  will  be  the  reward  in  production.  If  the  milk 
is  insufficient  for  both  babies,  partial  or  entire  meals  of 
artificial  food  may  be  substituted  for  the  wet-nurse's 
infant. 


52  INFANT   FEEDING. 

At  the  first  sign  of  an  acute  illness  on  the  part  of  the 
wet-nurse's  baby,  it  should  be  separated  entirely  from  the 
other  baby,  and  removed  from  the  breast;  its  illness 
should  be  given  the  same  serious  consideration  as  that  of 
the  other  infant,  so  that  the  mother's  anxiety  may  be  re- 
lieved. It  should  receive  as  much  of  its  mother's  milk 
as  can  be  spared.  This  can  be  expressed  from  the 
breasts  and  fed  from  a  bottle. 

Feeding  of  the  Wet-nurse's  Baby.  When  a  single 
infant  is  to  be  nursed,  the  second  baby  is  often  a  neces- 
sity in  the  promotion  of  the  development  and  stimulation 
of  her  breasts.  No  breast  can  be  developed  to  its  fullest 
capacity  with  the  breast-pump  or  hand  expressions.  It 
is  a  well-known  fact  that  the  breasts  will  respond  in  pro- 
portion to  the  demand  placed  upon  them,  and  in  most 
instances  during  the  first  few  weeks  of  the  premature's 
life,  when  its  demands  are  met  by  from  4  to  16  ounces  of 
milk,  the  wet-nurse  can  supply  sufficient  milk  for  both 
babies.  When  her  supply  becomes  insufficient  to  meet 
the  demands,  her  baby  can  be  put  upon  partial  bottle 
feedings  of  the  strength  as  indicated  by  its  age  and  de- 
velopment. The  progress  of  the  wet-nurse's  baby  has 
great  influence  on  her  peace  of  mind,  which  may  spell 
success  or  failure  in  her  ability  to  carry  out  her  work. 
When  the  premature  infant  gives  evidence  of  sufficient 
strength  to  be  placed  upon  the  breast,  we  have  found  the 
application  of  the  wet-nurse's  baby  to  the  other  breast  a 
very  valuable  expedient  in  aiding  the  flow  of  milk  into 
the  breast  which  is  to  be  nursed  by  the  weakling.  In 
many  instances  we  have  seen  the  milk  flow  from  the 
second  breast  by  this  method  so  freely  that  but  very  little 
effort  was  required  on  the  part  of  the  weakling  to  obtain 
its  food. 

2.  The  Hygiene  of  the  Wet-nurse. 

In  general,  everything  that  has  been  said  in  the  chap- 
ter on  hygiene  of  the  nursing  mother  applies  also  to  the 


WET-NURSING.  53 

wet-nurse — of  course,  with  the  proper  modifications, 
made  necessary  by  peculiarities  of  her  position. 

Her  clothes  should  be  simple,  and  in  every  part 
washable.  As  the  care  of  her  undergarments  is  of  even 
greater  importance  than  her  outer  clothing,  it  is  well  that 
her  laundry  should  be  done  with  the  family  work,  so  that 
the  family  laundress  who  is  trusted  by  the  family  may  be 
charged  with  its  inspection. 

To  simplify  nursing  or  the  drawing  of  milk,  the 
author  has  devised  two  garments  for  wet-nurses.  The 
material  used  for  the  outer  garment  is  of  yellow  gingham, 
such  as  is  used  in  the  making  of  hospital  uniforms,  the 
yellow  color  being  selected  to  distinguish  the  wet-nurse 
from  the  blue,  as  used  by  the  nursing  corps.  The  cor- 
set-waist is  to  be  made  of  heayy  muslin.  The  corset,  if 
worn  at  all,  should  be  of  a  very  low  type,  so  as  to  avoid 
all  pressure  on  the  breasts.  It  is  best  of  a  cheap  quality, 
so  that  it  can  be  replaced  frequently  for  sanitary  reasons. 
Each  wet-nurse  should  be  supplied  with  four  uniforms 
and  six  nursing  corset-waists. 

The  Diet  of  the  Wet-nurse.  There  is  danger  of  the 
creation  of  indolent  habits  through  neglect  of  regular 
exercise  and  the  lack  of  regular  household  duties,  but 
even  greater  danger  lies  in  the'  direction  of  overfeeding 
with  unusual  foods.  The  average  wet-nurse  is  either  ob- 
tained from  an  institution  or  a  home  in  which  the  lux- 
uries of  life  are  limited,  and  she  has  been  accustomed  to 
a  simple  nutritious  diet.  Every  attempt  should  be  made 
to  supply  the  nursing  woman  with  a  well-rounded  diet 
of  simple  foods,  with  milk  and  cereals  as  the  basis,  and 
these  supplemented  with  meats,  soups,  the  common  vege- 
tables, limited  amounts  of  fruits  and  plain  desserts.  In 
so  far  as  possible,  the  aromatic  vegetables,  unripe  and 
highly  acid  fruits,  fried  meats,  and  rich  pastries  are  to  be 
avoided.  We  believe  that,  on  the  whole,  too  great  stress 
has  been  laid  upon  the  danger  of  the  diet  in  the  mother 
of  a  full-term  infant,  and  in  most  cases  the  average 


54  INFANT   FEEDING. 

mother  can  partake  of  a  very  full  diet.  However,  in  the 
case  of  the  woman  nursing  premature  infants,  it  should 
become  a  custom  to  allow  only  such  foods  during  the 
first  few  days  after  her  installation  as  can  be  given  with 
perfect  impunity.  When  a  full,  free  flow  of  milk  is 
established,  other  vegetables  and  fruits  can  be  added, 
one  at  a  time,  and  after  each  addition  to  the  diet  a  try- 
out  should  be  given  the  milk.  We  have  on  numerous 
occasions  seen  marked  intestinal  distention  and  diarrheal 
attacks  following  even  seemingly  slight  indiscretions  of 
the  diet  on  the  part  of  the  wet-nurse.  It  is  our  hospital 
practice  to  furnish  each  wet-nurse  with  two  quarts  of 
good  wholesome  milk  daily,  and  at  least  one  pint  of 
cereal  gruel,  preferably  farina  or  corn-meal.  A  mixture 
of  milk  and  cereal  gruels  .makes  a  very  good  combination 
for  drinking  midway  between  meals.  The  remainder  of 
the  milk  may  be  taken  with  the  meals,  either  pure  or  in 
the  form  of  cocoa,  tea,  or  weak  coffee,  in  whichever  form 
it  is  best  taken  by  the  individual  woman.  The  latter  is  of 
considerable  importance,  as  in  the  forced  diets  which  are 
required,  where  an  abundance  of  milk  is  demanded,  dis- 
tasteful foods  soon  become  obnoxious  in  large  quan- 
tities. 

Beers,  malt-extracts,  and  other  rich  drinks  are  not 
forced  upon  the  nurse,  unless  she  is  accustomed  to  them, 
and  feels  their  need.  It  must  always  be  remembered  that 
an  excess  of  fluids  would  naturally  tend  to  dilute  the 
milk  unless  the  secreting  gland  be  of  exceptional  develop- 
ment. 

Exercise  of  the  Wet-nurse  and  Her  Work.  She 
should  be  impressed  before  her  engagement  with  the  fact 
that  she  will  be  required  to  do  a  moderate  amount  of 
work  and  exercise  regularly  out  of  doors.  The  former 
will  be  of  service  in  promoting  her  general  health,  and 
both  the  work  and  the  exercise  will  serve  as  a  nerve  tonic 
and  prevent  her  becoming  indolent.  This  does  not  mean 
that  she  should  become  a  drudge,  but  that  she  should  at 


WET-NURSING.  55 

least  be  required  to  care  for  her  own  room  and  her  own 
infant's  clothes,  and  should  be  made  to  feel  that  in  re- 
turn for  her  laundry  work  she  would  be  requested  to  do 
some  light  general  work  about  the  house.  Her  exercise 
in  the  open  air  should  so  far  as  possible  be  at  regular 
times.  The  question  as  to  the  care  of  the  napkins  of  both 
babies  is  open  to  considerable  discussion;  and  it  may  be 
stated  that  whenever  it  becomes  necessary  for  the  nurse 
to  express  her  milk  by  hand,  she  should  not  be  subjected 
to  the  handling  of  soiled  napkins,  whenever  this  can  be 
averted. 

Other  Conditions  Influencing  the  Quality 
of  the  Breast  Milk. 

The  nervous  and  mental  state  of  the  nurse  is  of  the 
utmost  importance,  and  wherever  possible  an  emotional, 
nervous,  erratic  woman  should  be  excluded,  because  of 
the  tendency  of  these  influences  to  suppress  the  flow  of 
milk.  Therefore,  whenever  possible,  a  woman  of  more 
or  less  phlegmatic  temperament  is  to  be  selected.  This 
is  especially  true  in  the  case  of  a  woman  who  is  to  be 
in  close  contact  with  and  is  to  nurse  an  infant  with  neu- 
rotic tendencies.  There  is  also  the  possibility  of  the  same 
influence  being  manifest  in  time  of  slight  indisposition 
on  the  part  of  her  own  infant,  and  such  an  individual  is 
also  more  likely  to  resent  the  necessity  of  partial  or  en- 
tire artificial  feeding  of  her  own  child  to  the  advantage  of 
the  premature  infant,  when  it  has  reached  such  an  age 
when  it  may  make  greater  demands  on  her  supply. 

Menstruation  rarely  produces  any  serious  disturb- 
ances. It  is  always  a  safe  procedure  to  dilute  the  milk 
during  the  first  and  the  second  day  of  menstruation  when 
the  nurse  suffers  considerable  pain  at  these  times. 

Period  of  lactation  may  or  may  not  be  a  considerable 
factor,  depending  upon  the  individual  woman.  We  had 
in  our  employ  a  nurse  who  had  been  with  the  institution 
for  sixteen  and  a  half  months,  and'  whose  infant  was 


56  INFANT   FEEDING. 

eighteen  months  old,  and  who  supplied  us  with  the  largest 
quantity  and  the  best  quality  of  milk  of  the  four  nurses 
in  the  institution.1  When  possible  a  nurse  should  be 
selected  after  the  first  few  weeks  of  lactation,  at  which 
time  the  colostrum  has  disappeared  from  the  milk,  and 
the  quantity  and  quality  of  her  milk  has  become  estab- 
lished. After  the  first  few  weeks  of  lactation,  but  little 
or  no  attention  is  to  be  paid  to  the  age  of  the  wet-nurse's 
baby  as  compared  with  that  of  the  infant  to  be  fed,  and 
we  have  never  noted  any  ill  effects  following  this  rule. 

3.  The  Nursing. 

The  Infant's  Bedroom.  Under  ideal  circumstances, 
this  should  be  separated  from  that  of  the  wet-nurse. 
This  is  especially  true  where  a  trained  attendant  has  care 
of  the  infant.  It  should  under  all  circumstances  also  be 
separated  from  the  wet-nurse  when  she  is  of  a  low  de- 
gree of  intelligence  and  of  a  type  not  to  be  trusted  with 
the  care  of  the  infant. 

Methods  of  Drawing  Milk.  Numerous  methods  of 
obtaining  milk  from  the  breasts  have  been  described,  but 
only  those  most  practicable  of  application  will  be  de- 
tailed. These  should  be  divided,  first,  into  those  in  which 
the  baby  is  placed  directly  at  the  breast,  and  those  meth- 
ods by  which  the  milk  is  drawn  from  the  breasts  and  fed 
to  the  infant.  Two  methods  are  especially  applicable 


1  The  milk  of  this  nurse  was  examined  in  the  laboratories  of" 
the  University  of  Chicago  after  seventeen  months  of  lactation 
with  the  following  result : 

Albumin    1.30  per  cent. 

Casein 0.69 

Fat  3.54  "       " 

Lactose   7.025  " 

Salts   0.1885  " 

It  must  be  remembered  that  this  is  an  exceptional  case,  and  but 
few  women  under  the  stress  of  ordinary  life  can  properly  nurse 
their  infants  after  the  ninth  to  twelfth  month, 


WET-NURSING. 


57 


where  the  baby  is  fed  directly  on  the  breast,  and  needs 
assistance  because  of  its  weakness. 

1.  Premature  infant  is  placed  at  the  breast,  and  is 
supported  there  by  the  nurse's  right  arm  while  nursing  at 
the  right  breast,  and  the  left  hand  is  used  to  grasp  the 
breast  just  above  the  nipple  between  two  ringers  (see 


Fig.  1. — Proper  method  of  holding  baby  during  nursing. 

Fig.  1 ) ,  and  the  milk  is  expressed  directly  into  the  baby's 
mouth.  In  this  way  the  baby  is  taught  to  take  the  breast, 
and  at  the  same  time  receives  its  food  with  little  effort. 
This  method  can  be  continued  until  the  baby  has  gained 
sufficient  strength  to  nurse  without  assistance. 

2.  Much  of  the  same  result  can  be  accomplished  by 
placing  the  wet-nurse's  baby  on  the  opposite  breast  dur- 
ing the  nursing  period,  whereupon  the  simultaneous  nurs- 
ing on  both  breasts  will  cause  a  free  flow  of  milk  into 
both  sides. 


58  INFANT    FEEDING. 

In  those  methods  by  which  the  milk  is  drawn  from  the 
breasts  and  fed  to  the  infant  by  hand  or  by  other  means. 

1.  By   the   breast-pump.      The   modification   of    Holz 
vacuum  apparatus,  as  devised  by  the  author,  by  which 
means  the  milk  is  drawn  directly  into  two  graduated  2- 
ounce  flasks,  which  can  be  filled  to  the  quantity  desired, 
and  stoppered  for  future  use,  so  that  the  milk  is  free 
from  handling,  and  thereby  avoid  contamination. 

2.  By  direct  expression,  which  is  performed  as  fol- 
lows: 


Fig.  2. — Author's  improved  breast  milk  collector.  The  pump 
is  made  in  two  types,  the  first  filled  with  a  large  rubber 
bulb  of  a  size  considerably  larger  than  is  ordinarily  sold 
with  a  breast-pump,  and  the  second  with  an  attachment 
to  which  the  Holz  vacuum  pump  can  be  fitted.  In  place  of 
the  ordinary  collecting  bulb  at  the  lower  surface,  an  arm  is 
so  constructed  as  to  allow  the  milk  to  drain  into  specially 
designed  graduated  2-ounce  milk  flasks. 

Instructions  for  the  Expression  of  Breast  Milk. 

Scrub  the  hands  and  nails  with  soap,  warm  water  and 
a  nail  brush  for  at  least  one  full  minute.  Wash  the  nip- 
ple with  fresh  absorbent  cotton  and  boiled  water  or  a 
freshly  made  boric  solution.  Dry  the  hands  thoroughly 
on  a  clean  towel  and  keep  them  dry.  Have  a  sterilized 


WET-NURSING.  59 

graduate  glass  tumbler  or  large  mouth  bottle  to  receive 
the  milk. 

1.  Grasp  the  breast  gently  but  firmly  between  the 
thumb  placed  in  front  and  the  remainder  of  the  fingers 
on  the  under  surface  of  the  breast.  The  thumb  in  front 
and  the  first  finger  beneath  should  rest  just  outside  of 
the  pigmented  area  of  the  breast. 


Fig.  3. — Direct  expression  of  milk  (act  1). 

2.  With   the  thumb  a   downward   pressing  motion   is 
made  on  the  front  against  the  fingers  on  the  back  of  the 
breast,  and  the  thumb  in   front  and  fingers  behind  are 
carried  downward  to  the  base  of  the  nipple. 

3.  This  second  act  should  end  with  a  slight   forward 
pull  with  gentle  pressure  at  the  back  of  the  nipple  which 
causes  the  milk  to  flow  out. 


60  INFANT   FEEDING. 

The  combination  of  these  three  movements  may  be 
described  as  "Back-down-out." 

It  is  not  necessary  to  touch  the  nipple. 

This  act  can  be  repeated  thirty  or  sixty  times  per  min- 
ute after  some  practice. 


Fig.  4. — Direct  expression  of  milk   (act  2). 

Both  breasts  may  be  emptied  if  necessary  or  they  may 
be  used  alternately. 

The  milk  should  be  covered  at  once  by  a  sterile  cloth 
held  in  place  by  a  rubber  band  and  kept  on  ice  until  used. 

Daily  Number  of  Expressions.  Expression  is  per- 
formed six  times  daily  at  regular  intervals  of  four  hours 
during  the  day  and  night. 


CHAPTER    IV. 
THE   NURSING   INFANT. 

Signs  of  Successful  Nursing.  The  normal  full-term 
infant  shows  a  gain  of  not  less  than  4  ounces  weekly. 
This  is  the  minimum  weekly  gain  which  may  safely  be 
allowed.  When  a  nursing  baby  remains  stationary  in 
weight  or  makes  a  gain  of  but  2  or  3  ounces  a  week,  it 
means  that  something  is  wrong,  and  the  defect  will  usu- 
ally, but  not  invariably,  be  found  in  the  milk  supply. 
When  the  baby  is  nursed  at  proper  intervals,  and  the 
supply  of  milk  is  ample  and  of  good  quality,  it  is  satis- 
fied at  the  completion  of  the  nursing.  Under  three 
months  of  age  it  falls  asleep  after  ten  or  twenty  minutes 
at  the  breast.  When  nursing  period  again  approaches,  it 
becomes  restless  and  unhappy,  crying  lustily  if  the  nurs- 
ing be  delayed.  When  the  breast  is  offered,  it  takes  it 
greedily.  The  weekly  gain  in  weight  under  such  condi- 
tions is  usually  from  4  to  8  ounces.  At  the  fifth  month 
the  baby  will  have  doubled,  and  at  the  twelfth  month 
trebled  its  birth  weight.  The  average  gain  per  week  dur- 
ing the  first  year  is  about  4  ounces. 

The  baby  increases  in  length  from  about  20.5  inches 
(50  cm.)  to  28.5  inches  (70  cm.)  in  the  first  year.  The 
first  tooth  appears  at  about  the  sixth  or  seventh  month, 
and  at  one  year  there  should  be  six  teeth  or  more.  (Age 
in  months  minus  6  =  number  of  teeth  normally  present 
at  that  age.)  It  begins  to  smile  at  about  the  fifth  week, 
grasps  objects  and  holds  its  head  erect  in  the  fourth 
month,  sits  alone  for  a  few  minutes  at  seven  or  eight 
months,  bears  its  weight  on  its  feet  at  the  ninth  or  tenth 
month,  stands  with  slight  assistance  at  the  eleventh  or 
twelfth  month,  and  creeps  or  walks  soon  after  this  (tenth 
to  eighteenth  month,  average  fourteenth  month),  and 
says  a  few  words  towards  the  end  of  the  first  year. 

Stools.  The  feces  of  breast-fed  babies  are  strikingly 
uniform,  and  are  like  no  other  bowel  movement  in  in- 

(61) 


62  INFANT   FEEDING. 

fancy.  Normally,  there  are  two  or  three  a  day,  some 
times  only  one,  or  even  more  than  three.  They  are  soft, 
or  mushy,  homogeneous,  of  an  egg-yellow  or  gold  color, 
and  have  a  slightly  sour,  not  at  all  unpleasant  odor.  They 
are  never  formed,  and  always  cling  to  the  diaper.  The 
nature  of  the  bowel  movement,  and  its  uniformity,  is  due 
to  the  "physiological  fecal  flora"  which  is  brought  about 
by  the  ingestion  of  breast  milk  into  the  germ-laden  in- 
testinal tract,  and  which  in  turn  have  a  fermentative 
rather  than  a  putrefactive  action  on  the  food.  The  gases 
normally  formed  are  carbon  dioxide  and  hydrogen,  and 
these  are  practically  odorless.  The  acidity  of  the  move- 
ment, its  softness,  and  the  mechanical  action  of  the  gases 
present,  all  insure  active  peristalsis  and  ready  emptying 
of  the  bowels,  so  that  constipation  is  an  exceptional  con- 
dition in  a  breast-fed  baby,  and,  if  present,  it  nearly  al- 
ways suggests  too  little  food,  or  abdominal  and  intestinal 
muscles  too  little  developed  and  too  weak  to  force  the 
stool  past  the  anal  sphincter.  This  latter  condition  is 
commonly  interpreted  as  constipation  by  the  laity. 

The  dried  residue  of  the  feces  contains  from  10  to  30 
per  cent,  of  fat,  about  8  per  cent,  salts,  a  very  large  per- 
centage of  bacteria,  bile  pigments,  intestinal  secretion 
(mucus,  etc.),  epithelial  cells,  etc.  No  food  proteins  or 
carbohydrates  are  found. 

The  feces  of  the  breast-fed  baby  are  very  frequently 
not  wholly  normal ;  they  quite  commonly,  especially  dur- 
ing the  first  few  months,  contain  small,  soft,  white  or 
yellowish  fat  curds,  an  excess  of  mucus,  and  are  often 
greenish  in  color,  and  may  be  more  frequent  than  nor- 
mal. Such  a  condition  is  perfectly  consistent  with  a  nor- 
mal growth  and  well-being  of  the  baby,  and  should  never 
in  itself  be  a  cause  of  worry,  or  an  indication  for  a 
change  .-of.:. f.0.od.  This  is  a-v«£y  important  point  that  is 
very  commonly  neglected.  The  condition  ofH;he  bowel 
movements  is  only  one  factor,  and  in  the- breast- fed  a 
minor  one,  in  determining  a  baby's  nutrition. 


CHAPTER    V. 
MIXED    FEEDING    AND    WEANING. 

Mixed  Feeding  (allaitement  mixte).  With  a  dimi- 
nution in  the  amount  of  milk  secreted,  the  breast  milk 
must,  of  course,  be  complemented  or  supplemented  by 
modified  cow's  milk.  These  methods  of  feeding  are  usu- 
ally successful.  By  complemented  feeding  we  mean  the 
administration  of  milk  from  a  bottle  following  a  period  at 
the  breast  at  each  nursing.  By  supplemental  feeding  sub- 
stitution of  a  bottle  for  a  breast  feeding  is  meant.  Thus, 
in  the  former  the  baby  receives  as  many  part  bottle  as 
breast  feedings,  while  in  the  latter  it  will  be  supplied  with 
one  or  more  bottle  feedings  to  replace  breast  feedings. 
As  we  know  that  the  breast  secretes  in  proportion  to  its 
stimulation,  the  complementary  feeding  is  far  more  satis- 
factory, and  not  infrequently  it  is  wise  to  nurse  both 
breasts  for  a  short  time,  let  us  say,  each  one  five  to  ten 
minutes,  before  the  bottle  is  given. 

It  is  necessary  to  weigh  the  infant  before  and  after 
nursings  for  one  or  more  days  to  obtain  a  fair  idea  of 
the  amount  of  cow's  milk  mixture  that  it  will  be  neces- 
sary to  administer  in  cases  of  underfeeding  at  the  breast. 
Given  a  normal  infant  weighing  ten  pounds,  the  food 
value  of  twenty-five  ounces  of  breast  milk  should  be  ap- 
proximated (%  of  his  body  weight). 

Clinical  experience  has  taught  us  that  most  infants  will 
thrive  on  artificial  mixtures  approximating  the  food  val- 
ues contained  in  breast  milk.  Roughly,  npgjmd  one-half 
ounces  (45  mils)  of  cow's  milk  to  which  %o  ounce 
grams)  of  sugar,  cane  or  milk,  and  one  ounce  ot  water 


has  been^  added,  will  meet  the  requirements  for  each 
pound  body,  weight  (y»  kilo).  Such  a  mixture  will  con- 
tain F-2AP-2~1,  C-6.7  per  cent. 

(63) 


64  INFANT   FEEDING. 

Example:  A  ten-pound  infant  receiving  15  ounces  of 
breast  milk  is  receiving  two  and  one-half  ounces  for  each 
six  pounds  of  his  body  weight  and  will  require  in  addi- 
tion the  equivalent  of  two  and  one-half  ounces  for  each 
of  four  pounds  body  weight  which  can  be  supplied  by 
six  ounces  (one  and  one-half  times  four)  of  cow's  milk 
and  four-tenths  of  an  ounce  of  sugar.1  To  meet  his 
water  requirements,  the  mixture  should  be  made  10 
ounces,  adding  four  ounces  of  boiled  or  cereal  water. 

The  cow's-milk  mixture  is  best  fed  in  part  after  each 
breast  nursing.  By  giving  both  breasts  at  each  feeding 
they  receive  the  maximun  amount  of  stimulating.  The 
infant  may  be  fed  at  three-  or  four-hour  nursing  periods. 

For  the  thin  infant  breast  milk  plus  substitute  feedings 
must  approximate  the  requirements  of  his  full  weight  for 
his  age. 

In  beginning  the  use  of  cow's  milk,  however,  it  must 
be  remembered  that  at  first  a  weaker  strength  must 
be  used  than  the  child  will  require  for  growth,  this 
weaker  food  being  necessary  in  order  gradually  to  ac- 
custom the  infant  to  the  change.  If  too  strong  a  cow's 
milk  mixture  is  given  at  first,  it  will  be  very  apt  to 
disagree,  causing  colic  and  vomiting.  Later,  when  the 
child  has  become  accustomed  to  the  new  food,  a  stronger 
mixture  may  be  given.  When  a  mother  cannot  give 
her  infant  at  least  two  satisfactory  breast  feedings 
daily,  it  is  advisable  to  wean  the  child..  The  new- 
born baby  is  not  very  discriminating,  and  will  nurse 
anything  equally  well.  The  older  baby,  however,  quickly 
prefers  the  easy-flowing  bottle  to  the  increasingly  un- 
satisfactory breast,  and  will  quite  regularly  stop  nursing 
at  the  breast  as  the  milk  comes  harder  and  is  less  abun- 
dant. If  the  bottle  is  given  right  after  the  breast,  it  is 
always  well  to  use  a  nipple  from  which  the  milk  comes 
with  some  difficulty,  for  the  reasons  given  above.  If  it 


1  Cane    sugar — two    level   tablespoonfuls    equals    one   ounce. 
Milk    sugar — three   level    tablespoonfuls    equals    one    ounce. 


MIXED    FEEDING   AND   WEANING.  65 

is  desirable  to  wean  the  baby  rather  quickly,  this  method 
of  following  the  breast  by  the  bottle  is  often  to  be 
preferred  to  the  other. 

Indications  for  Weaning.  Pregnancy  is  usually  an 
indication  for  weaning.  The  mother's  milk  becomes 
more  scanty,  and  often  poor  in  quality.  This  is  especially 
the  case  if  the  mother  knows  she  is  pregnant,  and  has 
been  taught  that  a  pregnant  woman  should  never  nurse  a 
baby.  If  the  baby  continues  to  thrive  at  the  breast,  there 
is  no  reason  why  nursing  should  not  be  prolonged.  For- 
tunately a  new  pregnancy  does  not  often  supervene  be- 
fore a  time  that  makes  it  quite  safe  to  wean  the  nursing 
baby,  i.e.,  before  the  sixth  month. 

In  acute  infections  in  the  mother,  such  as  pneumonia, 
and  the  acute  contagious  diseases,  such  as  scarlet  fever, 
one  must  weigh  the  danger  from  exposure  to  infection  as 
against  the  quality  of  the  artificial  food  and  environ- 
ment in  the  individual  case. 

In  the  milder  contagious  diseases,  such  as  measles, 
mumps,  it  is  true  that  young  breast-fed  infants  are  rarely 
infected.  Pertussis  is  an  exception,  and  has  a  high  mor- 
tality in  the  newborn  and  young  infants;  and  the  infant 
should  under  all  circumstances  be  protected  from  ex- 
posure. In  the  presence  of  diphtheria  the  infant  can  be 
immunized  with  safety. 

Weaning  should  always  be  done  gradually,  when  pos- 
sible, for  the  sake  of  both  mother  and  the  child.  In 
cases  of  sudden  weaning,  the  food  must  be  very  much 
weaker  in  the  beginning  than  for  an  artificially  fed  child 
of  the  same  age.  If  weaned  at  six  months,  the  infant 
should  be  put  on  a  mixture  suitable  for  a  child  of  two  or 
three  months,  and  the  same  rule  applies  for  older  infants. 
When  the  infant  becomes  accustomed  to  cow's  milk,  the 
strength  can  gradually  be  increased.  Rarely  should 
breast  feeding  be  continued  beyond  the  first  year. 

The  fear  of  the  laity  of  the  "second  summer"  is  well 
founded  when  dirty  milk  and  other  improper  foods  are 

5 


66  INFANT   FEEDING. 

fed  promiscuously,  but  with  clean,  certified,  and  sterilized 
milk,  and  properly  prepared  soft  foods,  the  dangers  of 
the  summer  heat  are  minimized.  It  should  be  our  rule 
to  underfeed  rather  than  overfeed  in  hot  weather,  and 
during  the  hot  spells  the  infant's  diet  may  well  be  re- 
duced one-half. 

Care  of  the  Breasts  During  Weaning.  When  the 
breast  feeding  is  carried  on  the  usual  length  of  time 
(from  nine  to  twelve  months),  the  process  of  weaning 
ordinarily  causes  little  or  no  discomfort.  All  that  is  usu- 
ally required  is  to  press  out  enough  of  the  milk  to  re- 
lieve the  patient  as  often  as  the  breast  becomes  painful, 
which  may  not  be  more  than  two  or  three  times  a  day. 
When  the  weaning  is  necessarily  abrupt,  no  little  dis- 
comfort may  result.  When  the  weaning  can  be  accom- 
plished more  gradually,  the  infant  should  have  one  less 
nursing  every  second  or  third  day,  until  only  two  are 
given  daily.  After  this  has  been  practised  for  one  week, 
nursing  should  be  discontinued.  In  cases  of  sudden 
weaning,  a  saline  laxative,  such  as  citrate  of  magnesia  or 
Rochelle  salts,  should  be  given  every  day  for  five  days — 
sufficient  to  produce  two  or  three  watery  evacuations 
daily.  In  the  meantime  the  mother  should  abstain  from 
fluids  of  all  kinds  up  to  the  point  of  positive  discomfort. 
The  breasts  should  be  elevated  by  a  firm  binder. 


CHAPTER    VI. 

NUTRITIONAL    DISTURBANCES    IN    THE 
BREAST-FED  INFANT. 

BREAST  milk  alone  furnishes  all  of  the  needs  for 
growth  and  development  of  the  human  offspring.  The 
infant  will  thrive  in  most  instances  on  breast  milk  from 
different  sources  and  different  quality,  demonstrating  the 
ability  of  the  average  infant  to  assimilate  the  food  which 
Nature  intended  for  its  use,  even  though  the  percentage 
quantity  of  the  various  components  may  vary  greatly. 
Disturbances  in  the  breast-fed  baby  are  dependent  up_on 
one  or  more  of  several  factors.  In  the  order  of  their  fre- 
quency they  may  be  divided,  as  follows. 

1.  Underfeeding. 

2.  Overfeeding. 

3.  Congenital  debility,  with   resulting  impairment  of 
the  vital  functions. 

4.  Intercurrent     parenteral     (pharyngitis,     tonsillitis, 
bronchitis,    pneumonia,    pyelitis,    etc.)    and    enteral    in- 
fections. 

5.  Idiosyncrasy  towards  mother's  milk. 

While  all  nutritional  disturbances  in  young  infants  are 

foi  serious  import,  they  are  far  less  dangerous  than  those 

I  of  the  artificially  fed  infant,  and  much  more  easily  cor- 

\rected.    They  are  also  much  less  frequent  than  nutritional 

disturbances  in  artificially  fed  infants. 

1.  Underfeeding. 

Etiology.  Two  factors  of  prime  importance  must 
be  investigated  to  complete  the  diagnosis: 

( 1 )  The  daily  quantity  of  the  milk  furnished  to  the 

infant. 

(2)  The  quality  of  the  milk  supplied  by  the  mother. 

(67) 


68  INFANT   FEEDING. 

The  milk  may  contain  the  normal  percentage  of  fat, 
sugar,  and  protein,  but  be  scanty  in  amount.  Instead  of 
the  4  or  5  ounces  to  which  the  child  is  entitled,  it  may 
get  but  1  or  2  ounces.  Whether  or  not  the  quantity  is 
sufficient,  may  be  determined  by  weighing  the  baby  be- 
fore and  after  each  nursing  for  twenty-four  hours. 
(The  ordinary  spring  balance  infant  scale  will  not 
answer,  and  a  simple  beam  scale  with  weights  and  scoop 
should  be  supplied.)  One  ounce  of  breast  milk  weighs 
practically  1  ounce  avoirdupois.  By  nursing  for  fifteen 
minutes,  a  child  under  one  week  old  should  gain  1  to  1.5 
ounces;  at  three  weeks  of  age,  1.5  to  2  ounces;  four  to 
eight  weeks  of  age,  2  to  3  ounces ;  eight  to  sixteen  weeks 
of  age,  3  to  4  ounces;  sixteen  to  twenty- four  weeks  of 
age,  5  to  7  ounces;  six  to  nine  months  of  age,  6  to  8 
ounces ;  nine  to  twelve  months  of  age,  8  to  9  ounces.  Of 
course,  arbitrary  limits  cannot  be  fixed  as  to  the  quan- 
tity. It  is  not  necessary  to  worry  about  the  quantity 
taken  at  individual  feedings  so  long  as  the  infant  is  mak- 
ing satisfactory  gains  in  weight,  and  the  general  progress 
is  good. 

Quantity  of  Human  Milk  Required  by  the  Nursing 
Baby.  Babies  of  the  same  age  and  weight,  under  the  same 
conditions,  will  take  nearly  the  same  amount  of  food.  The 
older  and  larger  the  baby,  the  larger  the  total  quantity  of 
food  required,  but  its  energy  quotient — that  is,  the  num- 
ber of  calories  per  kilogram  or  a  pound  of  weight — lessens 
steadily  with  increasing  age.  The  daily  amount  that  nor- 
mal, thriving  babies  take  from  the  breast  can  be  stated 
at  about  one-sixth  to  one-fifth  of  their  body  weight  dur- 
ing the  first  month,  about  one-sixth  to  one-seventh  up  to 
the  sixth  month,  and  about  one-eighth  after  the  sixth 
month.  Heubner  expressed  this  in  terms  of  energy 
quotient,  as  follows:  "During  the  first  few  months  an 
infant  requires  100  calories  per  kilogram  daily  of  breast 
milk;  after  the  sixth  month  this  energy  quotient  gradually 
comes  down  to  80  or  85  at  the  end  of  the  first  year.  An 


NUTRITIONAL   DISTURBANCES.  69 

energy  quotient  of  70  is  about  the  minimum  amount  that 
an  infant  can  take  without  losing  weight."  Human  milk 
can  be  estimated  at  21  calories  per  ounce,  and  about  70 
calories  per  100  Gm.  of  milk.  With  these  figures  in 
mind,  it  is  easy  to  determine  whether  a  breast-fed  infant 
gets  about  the  right  amount  of  food,  and  we  have  also  a 
valuable  standard  by  which  to  measure  the  food  of  an 
artificially  fed  infant. 

Symptoms.  Failure  to  gain  weight  properly,  or  even 
a  loss  in  weight,  may  be  the  first  positive  evidence  of  an 
insufficient  food  supply.  Usually  this  is.  associated  with 
more  or  less  evidence  of  dissatisfaction  on  the  part  of  the 
infant.  The  infant's  sleep  becomes  disturbed,  and  it 
becomes  restless,  and  cries  long  before  the  next  feeding 
time.  Again,  it  may  manifest  its  dissatisfaction  by  nurs- 
ing greedily  for  a  short  time,  releasing  the  breast  and 
crying.  It  returns  to  the  breast  again,  but  with  the  same 
result ;  or  in  other  instances  the  infant  will  remain  at  the 
breast  for  much  longer  periods  than  should  be  necessary 
to  obtain  the  food  that  it  needs,  which  should  be  accom- 
plished in  from  ten  to  twenty  minutes. 

Usually  the  stools  are  normal  in  appearance,  but  small 
in  amount,  and  give  little  evidence  of  the  cause  of  the 
trouble.  However,  if  the  food  supply  be  decidedly  in- 
sufficient, we  may  have  a  positive  evidence  of  the  under- 
feeding by  the  appearance  of  the  so-called  "hunger 
stools,"  which  are  of  more  or  less  brownish  or  greenish- 
brown  color,  containing  little  fecal  matter  and  much 
mucus. 

If  the  condition  is  not  corrected,  the  baby  becomes 
weak  and  apathetic,  the  skin  loses  its  turgor,  the  tem- 
perature becomes  subnormal,  it  is  pale  and  anemic,  the 
fontanelles  become  depressed,  and  the  abdomen  sunken. 
Whenever  there  is  room  for  doubt  as  to  the  cause  of  this 
group  of  symptoms,  the  scale  will  be  the  most  positive 
evidence. 


70  INFANT   FEEDING. 

Treatment.  Undue  haste  in  removing  the  baby  from 
the  breast  offers  the  greatest  danger  in  the  treatment  of 
underfeeding,  and  should  be  resorted  to  only  when  other 
means  fail. 

Mixed  Feeding  should  be  instituted  when  the  breast 
milk  supply  is  inadequate.  (See  page  63.) 

The  ability  to  increase  the  quantity  of  milk  secreted 
by  the  average  woman  must  necessarily  vary  directly 
with  the  quantity  and  quality  of  the  glandular  tissue 
composing  the  breast.  However,  to  a  certain  extent 
at  least,  certain  factors  will  more  or  less  directly  in- 
fluence the  quantity  and  quality  of  the  secretion,  and  they 
are  worthy  of  our  attention. 

Means  of  Stimulating  the  Breasts.  The  surroundings 
of  the  mother  must  predispose  to  a  happy  frame  of  mind ; 
she  must  not  be  overburdened  with  household  cares ;  her 
exercise  must  be  regular,  and  she  must  be  relieved  of 
worry  and  lack  of  sleep.  It  is  well,  if  possible,  to  free 
her  from  all  care  of  the  baby,  especially  at  night.  She 
should  be  put  in  as  good  physical  condition  as  possible; 
she  should  get  out  of  doors. 

Giving  both  breasts  at  each  feeding  and  temporarily 
shortening  the  nursing  periods  to  3  or  even  2  hours, 
thereby  increasing  the  number  of  feedings,  are  the  best 
stimulants  available. 

Her  appetite  should  be  stimulated,  so  that  she  will  take 
an  abundance  of  milk  and  other  nutritious  food.  The 
very  common  forced  feeding  beyond  the  natural  appe- 
tite, is  of  questionable  value.  The  general  rules  as  to  the 
diet  previously  spoken  of  should  be  maintained.  It 
should,  however,  be  remembered  that  an  excessive  diet 
may  be  assimilated  by  the  mother's  body  without  increas- 
ing the  flow  of  milk.  The  fluids  given  should  be  palat- 
able to  the  nursing  mother,  and,  as  previously  recom- 
mended, milk,  weak  tea,  cocoa,  farina,  oatmeal,  and  corn- 
meal  gruels  as  well  as  milk  soups  are  probably  the  best. 
The  fat  and  the  protein  of  the  milk  can  more  especially 


NUTRITIONAL  DISTURBANCES.  71 

be  influenced  by  the  diet.  The  fats  are  increased  by  over- 
feeding with  fats  and  carbohydrates,  with  little  or  no 
exercise.  They  are  reduced  by  limiting  these  articles  and 
substituting  vegetables,  and  by  increasing  the  amount  of 
exercise.  The  protein  is  also  increased  by  overfeeding 
and  limited  exercise.  The  carbohydrates  are  less  in- 
fluenced by  the  diet,  but  are  also  affected  by  an  excess 
of  carbohydrate  feeding.  Alcohol  in  the  form  of  malted 
drinks  has  a  temporary  influence  in  increasing  the  quan- 
tity of  milk  and  the  amount  of  fat.  The  effect  on  the 
protein  is  less  constant.  We  never  force  a  woman  to 
partake  of  alcoholic  liquors  unless  she  desires  them,  be- 
cause of  the  moral  as  well  as  of  the  physical  effect. 

Direct  Expression  is  the  best  means  of  breast  stimu- 
lation. 

Stimulating  massage  may  be  applied  to  the  breast  in 
such  a  manner  as  to  stimulate  the  whole  gland.  This 
can  best  be  accomplished  by  two  movements :  ( 1 )  by 
gently  raising  the  whole  breast  from  the  chest  wall  and 
kneading  it  gently  between  the  fingers,  and  (2)  by  hold- 
ing the  breast  against  one  hand  and  making  circular 
movements  around  the  periphery  with  the  outspread 
finger  tips  of  the  other  hand,  and  gradually  working  from 
its  base  towards  the  nipple. 

Baths  at  a  temperature  comfortably  cool  (80°  to  90° 
F.)  should  be  taken  daily  to  promote  her  general  health 
as  well  as  cleanliness.  These  should  be  followed  by  a 
brisk  rubbing  with  a  coarse  towel. 

Steaming  the  breasts  by  the  application  of  hot  towels 

[  covered  with  oiled  silk  two  or  three  times  daily  is  of 

I  decided  benefit. 

Galactagogues  of  any  material  value  for  permanent 
use  are  unknown.  Pituitrin  has  been  recommended  for 
temporary  stimulation.  We  have  not  had  much  experi- 
ence in  its  use.  General  tonics  will  often  improve  the 
digestion  and  tend  to  overcome  the  anemia,  and  in  this 


72  INFANT   FEEDING. 


way  improve  the  general  health,  and  thereby  lactation. 
^Feeding  dried  placenta  has  been  recommended. 


2.  Overfeeding. 

This  cpndition  is  a  rare  one  in  the  breast-fed  baby, 
and,  when  present,  in  all  but  the  very  young  and  pre- 
mature, nature  often  provides  its  own  remedy,  either  by 
regurgitation  on  the  part  of  the  baby,  or  by  its  refusal  to 
nurse  longer  than  to  meet  its  needs,  which  latter  soon 
leads  to  a  lessened  milk  secretion.  In  the  first  weeks  and 
months  it  may  be  of  considerable  importance,  and  may 
cause  grave  symptoms  on  the  part  of  the  infant  —  that  is, 
before  the  mother's  breast  and  the  infant  have  become 
adapted  to  one  another. 

Etiology.  Althougih  overfeeding  in  the  breast-fed 
infant  is  rare  when  compared  with  overfeeding  on  arti- 
ficial food,  yet  next  to  underfeeding  it  is  the  most  com- 
mon form  of  nutritional  disturbance  in  the  breast-fed 
infant.  It  is  also  more  commonly  present  in  infants  fed 
by  a  wet-nurse  than  in  infants  nursing  the  maternal 
breast. 

Usually  the  error  lies  in  too  frequent  nursing. 

Rarely  it  may  be  due  to  excessive  quantities  of  milk 
taken  at  proper  intervals. 

Occasionally  it  is  due  to  milk  which  is  excessively  rich 
in  fat. 

Pathogenesis.  The  normal  infant's  stomach  on 
breast  feeding  empties  itself  in  about  two  hours.  When 
all  the  food  has  left  the  stomach,  and  is  undergoing  intes- 
tinal digestion,  free  hydrochloric  acid  is  forming  in  the 
stomach.  Free  hydrochloric  acid  is  antiseptic,  and  it  also 
stimulates  secretion  of  pancreatic  juice  and  secretion  of 
bile,  both  of  the  latter  products  being  essential  to  proper 
intestinal  digestion. 

For  normal  digestion  it  is  therefore  necessary  that  the 
stomach  remain  empty  for  some  time  after  all  the  food 
has  left  it.  When  by  too  frequent  nursings  no  time  is 


NUTRITIONAL   DISTURBANCES.  73 

allowed  for  the  above  described  physiological  process,  or 
when  by  excessive  quantities  of  food  at  proper  intervals 
too  great  demands  are  made  upon  the  hydrochloric  acid, 
and  the  time  of  gastric  digestion  lengthened,  with  cor- 
responding shortening  of  the  period  of  comparative  rest, 
or  the  gastric  secretion  diminished  by  excessive  fat,  then 
we  may  expect  disturbance  of  the  normal  digestion  due 
to  overfeeding. 

Symptoms.  The  earliest  symptoms  are  regurgita- 
tion,  diarrhea,  and  lessened  appetite.  These  three  symp- 
toms are  reactions  of  the  organism  to  excessive  intake  of 
food  attempting  to  get  rid  of  the  excess. 

Regurgitation  occurs  at  first  occasionally  only,  imme- 
diately after  nursing,  and  without  any  discomfort  on  the 
part  of  the  infant  ("spitting").  The  regurgitated  fluid 
is  often  unchanged  milk.  This  is  usually  the  first  pre- 
monitory symptom. 

Diarrhea  follows  when  overfeeding  continues  and  re- 
gurgitation  becomes  insufficient  to  rid  the  body  of  excess 
of  food.  The  stools  are  more  frequent  than  normal,  and 
contain  undigested  particles  of  food. 

Lessened  appetite,  although  present  in  many  cases, 
may  be  replaced  by  symptoms  suggestive  of  hunger,  the 
infant  taking  the  breast  and  nursing  greedily.  This  ap- 
parent symptom  of  underfeeding  and  of  hunger  may 
wrongly  be  interpreted,  and  lead  to  additional  overfeed- 
ing by  giving  the  breast  at  even  more  frequent  intervals 
to  allay  the  apparent  hunger  and  to  quiet  the  restless 
infant. 

In  many  cases  no  other  symptoms  develop,  the  condi- 
tion undergoing  a  spontaneous  cure.  The  breasts  lessen 
their  yield,  and  thus  the  cause  of  the  condition  disap- 
pears, or,  on  the  other  hand,  the  digestive  power  of  the 
infant  increases  to  such  an  extent  as  to  be  able  to  take 
care  of  the  excess,  if  not  too  large.  This  accounts  for  the 
fact  that  frequently  the  above-named  symptoms  are 
neglected,  since  they  usually  produce  improvement  in 


74  INFANT   FEEDING. 

the  child's  condition,  and  are  regarded  as  passing  dis- 
turbances without  much  importance.  When,  however, 
they  are  entirely  neglected,  and  excess  of  the  food  is  con- 
tinued, or  even  increased,  due  to  wrong  interpretation  of 
symptoms,  then  more  serious  symptoms  develop,  and  the 
condition  reaches  a  stage  where  spontaneous  cure  rarely 
occurs. 

Vomiting  becomes  habitual,  occurring  from  a  few 
minutes  to  half  an  hour  after  nursing.  It  is  accom- 
panied by  visible  discomfort  and  straining  on  the  part  of 
the  infant.  The  vomitus  consists  of  curdled  milk,  mucus, 
and  gastric  juice.  Between  vomiting  there  is  often  pain- 
ful belching.  Stomach  shows  distention,  and  empties 
itself  only  after  three  to  four  hours.  Free  hydrochloric 
acid  is  almost  or  entirely  absent,  the  acid  products  of  fer- 
mentation being  present.  The  micro-organisms  are  in- 
creased in  number  and  variety,  due  to  stagnation  and  ab- 
sence of  antiseptic  free  hydrochloric  acid. 

Initial  diarrhea  is  sometimes  followed  by  temporary 
constipation,  diarrhea  setting  in  again.  The  evacuation 
is  painful,  and,  with  much  gurgling  and  discharge  of 
gases,  fluid  masses  are  squirted  from  the  anus.  The 
stools  are  watery,  with  white  and  dark  green  fragments, 
and  of  disagreeable,  sour,  pungent  odor.  The  irritating 
feces  often  causes  eczema  and  intertrigo  in  the  ano- 
genital  region. 

Abdomen  is  distended,  tense,  and  often  there  is  visible 
peristalsis.  Intestinal  colic  causes  restlessness  and  cry- 
ing; the  infant's  face  gives  expression  to  its  pain,  and,  as 
the  fermentation  increases,  its  agony  is  increased,  due 
to  intestinal  paresis. 

The  infant  becomes  restless;  its  sleep  is  much  dis- 
turbed, and  even  during  sleep  its  features  give  evidence 
of  its  distress. 

The  weight  early  becomes  stationary,  and  in  severer 
cases  associated  with  dyspepsia  loss  of  weight  becomes 
marked. 


NUTRITIONAL   DISTURBANCES.  75 

Complications.  Dyspepsia.  Accompanied  by  the 
milder  evidence  of  intestinal  irritation,  evidenced  by  in- 
creased peristalsis,  with  its  resultant  colic,  more  or  less 
numerous  bowel  movements  of  eight  or  ten  or  even  more 
daily,  sour  and  irritating,  greenish-yellow  in  color,  and 
containing  numerous  curds  and  much  mucus.  The  but- 
tocks soon  become  reddened  and  intertrigo  results. 

Intoxication,  while  rare  in  the  breast-fed  infant,  may 
result  when  the  dyspepsia  is  neglected.  The  baby  be- 
comes drowsy  and  stuporous,  paying  little  attention  to 
its  surroundings,  and  not  infrequently  develops  a  severe 
anorexia,  all  associated  with  more  profound  intestinal 
symptoms. 

In  dyspepsia  the  intestinal  findings  dominate  the  pic- 
ture, while  in  intoxication  they  share  their  prominence 
with  the  added  nervous  symptoms. 

Pyelitis  is  not  an  infrequent  complication  in  neglected 
dyspepsia  and  intoxication,  and  while  it  undoubtedly  is 
frequently  due  to  an  ascending  infection,  it  may  re- 
sult from  extension  through  the  blood  stream  or  the 
lymphatics. 

Eczema  not  infrequently  results  from  overfeeding  in 
the  breast-fed  infant,  and  is  usually  seen  in  the  fat  type 
of  infant  who  is  otherwise  healthy. 

Pylorospasm  and  gastric  dilatation  are  not  uncommon 
in  the  neglected  cases. 

Acidosis  may.  develop  in  the  extreme  cases,  associated 
with  great  loss  of  weight,  but  this  is  rare. 

Diagnosis.  In  the  presence  of  symptoms  suggestive 
of  overfeeding,  positive  diagnosis  is  made  by  determin- 
ing exactly  the  amount  of  milk  taken  by  the  infant,  and 
comparing  this  amount  with  what  an  infant  of  the  same 
weight  and  of -the  same  age  should  get.  The  method  of 
this  determination  has  been  described  in  detail  under  the 
treatment  of  underfeeding. 

If,  however,  the  food  is  found  to  be  quantitatively  cor- 
rect, occasionally  information  of  value  may  be  obtained 


76  INFANT   FEEDING. 

by  examining  the  quality  of  the  milk  chemically,  espe- 
cially as  to  its  fat  content.  The  specimen  for  examina- 
tion should  be  taken  under  precautions  pointed  out  under 
Examination  of  Human  Milk.  By  making  proper  etio- 
logical  diagnosis,  valuable  indications  for  rational  treat- 
ment are  obtained. 

If  a  careful  search  is  made  for  the  etiological  factors 
in  the  common  illnesses  of  infants,  which  are  so  fre- 
quently charged  to  overfeeding,  one  will  be  surprised  to 
find  that  the  error  lies  in  the  diagnosis,  and  that  in  most 
cases  the  condition  is  not  due  to  overfeeding.  This  leads 
us  to  warn  against  the  only  too  frequent  habit  of  wean- 
ing infants  without  a  careful  study  of  the  exact  cause 
of  the  infant's  trouble. 

Treatment.  Prophylaxis  of  this  disturbance  is  of 
importance,  and  consists  of  giving  the  nursing  mother 
proper  instructions  as  to  the  nursing,  especially  as  to  its 
frequency,  and  seeing  to  it  that  the  rules  for  nursing,  as 
laid  down  elsewhere,  are  observed  by  the  nursing  mother 
In  wet-nursing,  more  caution  is  necessary,  especially  in 
those  wet-nurses  who  have  an  abundance  of  milk,  which 
is  frequently  the  case  in  a  wet-nurse  whose  own  child  is 
much  older  than  the  infant  to  be  nursed. 

A  very  important  point  to  impress  both  on  the  mother 
and  also  on  the  wet-nurse  is  the  fact  that  crying  of  the 
infant  is  not  always  due  to  hunger,  and  that  offering  the 
breast  should  not  be  used  as  a  means  for  quieting  the 
child. 

When  the  initial  or  mild  symptoms  only  are  present, 
then  correction  of  the  nursing  habits  is  usually  sufficient, 
the  infant  improving  without  any  special  treatment. 

When  the  error  lies  in  too  frequent  nursings,  it  is  best 
and  often  completely  relieved  by  lengthening  the  feed- 
ing intervals  to  three  or,  even  better,  four  hours. 

It  is  of  equal  importance  that  the  infant  should  not  be 
left  too  long  at  the  breast.  The  best  average  nursing  time 
being  about  fifteen  minutes,  with  twenty  minutes  as  the 


NUTRITIONAL   DISTURBANCES.  77 

maximum.  However,  when  the  flow  of  milk  is  very  free, 
it  may  be  necessary  to  reduce  the  nursing  period  to  even 
three  to  five  minutes,  it  being  a  fact  that  most  infants 
take  about  75  per  cent,  of  their  entire  meals  in  the  first 
five  minutes  at  the  breast.  It  is  always  well  at  the  begin- 
ning of  such  an  experiment  to  weigh  the  baby  after  a 
two,  three,  five,  ten,  and  twenty  minutes  period  to  ascer- 
tain the  exact  amount  which  the  baby  obtains  from  the 
particular  breast  which  it  is  nursing,  so  that  conclusions 
may  be  drawn  definitely  as  to  the  time  it  is  to  be  left  on 
each  breast. 

If  placing  the  infant  at  the  breast  for  short  periods 
with  long  intervals  does  not  give  results,  it  is  advisable 
to  express  the  milk,  and  feed  in  small  quantities  from  the 
bottle.  And  if  another  baby  be  at  hand,  it  may  be  placed 
upon  the  breast  to  keep  up  the  supply.  Or  when  a  wet- 
nurse  is  available  for  temporary  use,  the  babies  may  be 
exchanged. 

Weaning  should  under  all  circumstances  be  considered 
only  as  the  last  resort,  after  all  other  methods  of  adapt- 
ing the  infant  to  the  breast  have  failed. 

An  excessive  amount  of  fat  in  the  milk  is  more  often 
due  to  an  excessive  intake  of  food  in  general  on  the 
mother's  part  than  an  excess  in  any  one  element,  and  can 
be  diminished  best  by  cutting  down  the  food  as  a  whole, 
lessening  the  amount  of  all  food. 

When  the  condition  has  progressed  farther,  and  the 
symptoms  have  become  more  serious,  then  it  is  necessary 
to  treat  the  infant  also.  The  treatment  consists  in  empty- 
ing the  stomach  and  the  bowels  of  the  overload  of  fer- 
menting food,  and  of  rest  for  the  digestive  apparatus, 
both  these  objects  being  achieved  by  giving  a  bland  diet, 
consisting  of  boiled  water  or  weak  tea  sweetened  with 
saccharin,  for  twelve  hours,  the  digestive  tract  getting  rid 
of  its  contents  spontaneously. 

If  the  symptoms  improve  upon  this  treatment,  the 
nursing  should  be  gradually  resumed  by  giving  two 


78  INFANT   FEEDING. 

breast  feedings  in  the  twenty-four  hours  following  the 
period  of  starvation,  substituting  for  the  other  nursings 
bland  liquids,  and  increasing  cautiously  the  number  of 
nursings. 

If  on  withholding  the  food,  vomiting  does  not  cease, 
then  it  is  necessary  to  wash  out  the  -stomach. 

Irrigation  of  the  bowel  is  often  necessary,  and  aids  in 
removal  of  fermenting  intestinal  contents,  and  allows 
also  the  gases  to  pass,  thus  relieving  the  distention  and 
colic.  Only  when  change  of  diet  and  irrigation  are  not 
sufficient,  then  the  use  of  purgatives  is  advisable,  castor 
oil  being  just  as  efficient  and  less  harmful  than  the  fre- 
quently preferred,  calomel. 

Colic  usually  disappears  on  correction  of  the  diet,  and 
after  the  intestinal  tract  has  been  cleansed  of  its  irritating 
contents,  and  of  gas.  Massage  to  the  abdomen  will  aid 
the  passage  of  gases  which  cause  distention,  when  the 
bowels  tend  to  become  paretic.  In  severe  pain,  warm 
applications  to  the  abdomen  give  relief.  If  these  meas- 
ures fail  to  bring  relief,  and  the  pain  is  such  that  the  in- 
fant is  deprived  of  sleep,  a  mild  sedative  in  small  doses 
may  be  given. 

Feeding  of  powdered  casein  in  amounts  varying  from 
6  to  8  Gm.,  dissolved  in  30  lo  60  mils  of  water,  two  or 
three  times  daily  will  relieve  colic  in  many  infants,  in 
all  probability  due  to  lessening  of  intestinal  peristalsis. 

There  is  a  class  of  infants  who,  although  they  are  gain- 
ing progressively  in  weight,  cry  a  great  deal,  expel  a 
great  deal  of  gas,  and  perhaps  have  a  green  stool  now  and 
then.  It  is  almost  criminal  to  take  such  infants  off  the 
breast,  although  the  temptation  to  do  so  is  very  great, 
because  of  the  worry  they  cause  the  mother,  and  conse- 
quent harassing  of  the  physician.  Such  an  infant  will 
frequently  cry  for  six,  eight,  ten,  or  twelve  hours  out  of 
the  twenty-four,  and  still  make  a  good  gain  in  weight 
each  week,  in  which  case  it  is  very  probable  that  the 
infant  is  being  overfed,  and  the  food  supply  should  be 


NUTRITIONAL   DISTURBANCES.  79 

reduced.     The  mother's  diet  and  general  habits  should 
receive  attention. 

3.  Congenital  Debility,  with  Resulting  Impair- 
ment of  Vital  Functions. 

Etiology.  Premature  birth  is  the  most  important 
condition  causing  debility  associated  with  deficient  func- 
tionating power  of  the  digestive  organs.  Method  of 
feeding  premature  infants  will  be  detailed  later  in  a 
special  chapter. 

Hereditary  weakness  of  the  offspring  caused  by  dis- 
ease in  the  parents  is  frequently  the  cause  of  deficient 
morphological  and  functional  development  of  the  diges- 
tive organs,  and  thus  it  is  often  the  underlying  cause  of 
nutritional  disturbances,  which  are  more  commonly 
chronic  in  character.  Tuberculosis,  syphilis,  and  alco- 
holism in  parents  stand  at  the  head  of  the  conditions 
causing  hereditary  weakness,  even  when  the  offspring 
does  not  inherit  the  disease  itself. 

Malformations  of  the  digestive  tract  (cleft  palate, 
sublingual  tumors,  pyloric  stenosis,  atresias  of  the  intes- 
tinal tract,  Hirschprung's  disease,  etc.)  from  any  cause 
compromise  its  functional  capacity  usually,  but  in  most 
cases  they  cause  serious  conditions  necessitating  surgical 
interventions,  and  only  rarely  do  they  produce  simple 
nutritional  disturbances  amenable  to  dietetic  means,  and 
therefore  they  belong  to  the  domain  of  surgery. 

Symptoms.  As  may  be  expected,  symptoms  of  these 
so  diverse  conditions  vary.  Hereditary  weakness  may 
often  be  suspected  when  symptoms  of  nutritional  dis- 
turbances develop  even  when  the  infant  is  given  the  best 
care  possible,  and  the  milk  is  quantitatively  and  quali- 
tatively correct.  Symptoms  of  underfeeding  or  of  over- 
feeding, as  described  previously,  may  be  present,  de- 
pending upon  the  etiological  factor. 

Diagnosis.  Careful  examination  for  malformations, 
and  thorough  family  history,  in  cases  of  suspected 


80  INFANT   FEEDING. 

hereditary  weakness  are  of  chief  importance  in  making 
the  etiological  diagnosis. 

Treatment  is  usually  determined  by  the  pathology, 
and  by  the  nature  of  the  particular  nutritional  disturb- 
ance which  developed. 

4.  Intercurrent  Parenteral  and  Enteral  Infections. 

Etiology.  Diseases  both  in  the  mother  and  in  the 
infant  are  to  be  considered  in  etiology  of  this  condition. 
In  the  mother  the  most  important  are  the  general  infec- 
tious diseases,  e.g.,  puerperal  fever  and  sepsis,  typhoid, 
pneumonia,  etc.,  and  local  infections  of  the  breast,  and 
also  of  the  upper  respiratory  passages.  In  the  infant 
there  are  parenteral  infections,  that  is,  infections  outside 
the  digestive  tract,  e.g.,  pharyngitis,  tonsillitis,  pneu- 
monia, pyelitis,  bronchitis,  and  enteral  infections,  or  in- 
fections of  the  intestinal  tract,  which  will  be  discussed 
under  a  special  heading. 

Symptoms.  In  the  conditions  dependent  on  the 
mother's  health  the  symptoms  will  vary  first  with  the 
quality  and  quantity  of  her  milk  supply,  which  will  have 
an  effect  on  the  child's  general  nutrition,  and,  secondly, 
may  result  in  direct  parenteral  or  enteral  infections  of 
the  infant. 

In  those  dependent  on  infections  of  the  infant  itself  we 
invariably  find  evidences  of  nutritional  disturbances, 
whether  the  infection  be  local,  systemic,  or  confined  to 
the  intestinal  tract.  The  clinical  picture  varies  directly 
with  the  degree  of  disturbance  of  the  metabolic  function. 
While,  as  a  rule,  the  enteral  infections  are  more  com- 
monly associated  with  grave  disturbances  of  the  infant's 
nutrition,  it  is  not  uncommon  to  find  the  infant  severely 
affected  in  its  ability  to  meet  its  nutritional  needs  by 
the  parenteral  infections.  While  any  one  of  the  above 
enumerated  etiological  factors  may  give  rise  to  a  marked 
clinical  picture,  it  is  to  be  remembered  that  this  class  of 


NUTRITIONAL   DISTURBANCES.  81 

disturbances  in  the  breast-fed  infants  are  of  minor  im- 
portance as  compared  with  those  of  the  artificially  fed 
(see  Nutritional  Disturbances  in  Artificially  Fed  In- 
fants). 

Diagnosis.  The  diagnosis  of  the  primary  seat  of  in- 
fection in  the  infant  is  of  considerable  importance  in  de- 
ciding the  method  of  treatment. 

Treatment.  Parenteral  infections  rarely  call  for  re- 
straint in  administration  of  food  because  of  the  asso- 
ciated anorexia,  and  the  infant  should  be  nursed  (if  pos- 
sible without  danger  to  the  mother)  directly  at  her 
breast. 

In  the  case  of  enteral  infections  it  may  be  necessary  to 
withdraw  the  maternal  milk  and  replace  it  by  a  short 
period  of  starvation,  to  be  followed  by  small  quantities  of 
breast  milk,  either  taken  directly  from  the  breast  during 
short  nursings,  or  it  may  be  best  to  feed  small  quantities 
of  expressed  milk  to  the  infant  at  regular  intervals. 

Not  infrequently  it  becomes  necessary  to  feed  these 
infants  by  catheter  in  order  to  sustain  them.  And  this 
method  of  introducing  their  food  should  be  begun  suffi- 
ciently early  to  avoid  a  catastrophe.  <. 

Under  no  circumstances  should  they  be  placed  upon 
food  other  than  the  mother's  milk  when  her  state  of 
health  and  the  quality  of  her  milk  permit. 

Inert  fluids,  such  as  water,  weak  tea,  broths  made  from 
young  meats  and  young  fowls,  and  cereal  decoctions 
should  be  given  between  feedings  to  insure  a  sufficient 
intake  of  water.  A  careful  record  should  be  kept  of  the 
twenty-four-hour  quantity  of  all  fluids  administered,  in 
order  to  insure  the  child  a  sufficient  water  and  food  ad- 
ministration. 

For  conditions  in  the  mother  which  would  justify 
weaning,  see  chapter  on  Weaning  and  Contraindications 
to  Nursing. 


82  INFANT   FEEDING. 

5.  Idiosyncrasy  Towards  Mother's  Milk. 

Etiology.  This  condition  is  very  rare,  although  it 
may  not  be  denied  that  it  exists.  The  etiology  and  patho- 
genesis  are  as  yet  little  understood. 

Diagnosis.  The  diagnosis  of  this  disturbance  should 
be  made  by  exclusion  of  all  other  causes  that  may  give 
rise  to  a  similar  symptom-complex.  It  may  be  confirmed 
by  the  change  of  the  milk  either  by  substituting  a  wet- 
nurse  or  cow's  milk  for  maternal  nursing,  whereupon  the 
symptoms  improve. 

The  cases  in  which  the  mother's  milk  is  totally  unfit 
for  the  infant  are  exceptionally  rare.  More  recently 
considerably  more  attention  has  been  given  to  the  effect 
of  the  mother's  diet  on  the  quality  and  quantity  of  her 
milk  secretion.  The  instruction  so  commonly  given  to 
the  mother,  to  the  effect  that  she  may  eat  whatever  she 
likes,  has,  in  the  light  of  more  recent  investigations, 
shown  need  for  modification.  The  effect  of  the  diet  of 
the  mother  on  the  milk  must  be  considered  under  two 
headings:  First,  what  foods  disagree  with  the  individual 
mother  to  the  extent  of  affecting  the  quantity  of  her  milk 
supply.  The  mother  will  be  the  best  judge  as  to  what 
foods  she,  herself,  finds  it  desirable  to  eliminate  from 
her  diet  because  of  an  undesirable  effect  upon  herself. 
More  important,  however,  from  the  standpoint  of  food 
idiosyncrasy,  is  the  result  following  the  eating  of  foods 
by  the  mother  which  she,  herself,  may  relish,  but  which 
may  have  an  undesirable  effect  on  the  child.  It  is  well 
known  that  eggs,  some  cereals,  fish  and  sea  foods,  certain 
meats,  chocolate,  and  even  cow's  milk  proteins  may  re- 
sult in  a  sensitization  of  the  infant  when  ingested  by  the 
mother.  The  more  recent  work  of  O'Keefe1  demon- 
strated the  frequency  of  such  a  sensitization  in  eczema. 
He  studied  forty-one  cases  of  this  condition  in  breast- 


1  O'Keefe:  Eczema  in  Breast-Fed  Babies,  Boston  Med.  and 
Surg.  Jour.  August,  1921 ;  185,  No.  6. 


NUTRITIONAL   DISTURBANCES.  83 

fed  infants,  and  61  per  cent,  of  his  cases  showed  a  posi- 
tive reaction  to  one  of  the  cow's  milk  proteins.  Forty- 
one  per  cent,  showed  a  positive  reaction  to  one  of  the 
egg  proteins,  two  cases  to  oats,  and  one  to  wheat.  About 
20  per  cent,  of  the  positive  cases  showed  a  response  to 
both  milk  and  egg  proteins.  Apparent  cure  in  about  20 
per  cent,  followed  the  omission  or  limitation  in  the  ma- 
ternal diet  of  one  or  more  food  proteins  to  which  the 
infant  was  sensitive. 


CHAPTER    VII. 

METHODS    OF   FEEDING    PREMATURE 
INFANTS. 

1.  Infants  Nursing  at  the  Breast. 

IN  most  cases  we  do  not  feed  the  more  developed  pre- 
mature infant  on  the  first  day.  It  may  be  wise,  however, 
to  place  the  infant  on  the  breast  two  or  three  times  dur- 
ing the  last  half  of  the  first  day,  after  the  circulatory  and 
respiratory  functions  are  well  established,  so  that  the  in- 
fant may  become  accustomed  to  nursing.  We  are  now 
confronted  with  two  important  factors,  first,  the  ability 
of  the  infant  to  nurse  the  breast ;  and  secondly,  sufficient 
and  proper  development  of  the  nipples  to  allow  of  the 
infant's  properly  grasping  the  same.  If  the  infant  is 
sufficiently  developed  to  take  hold  of  a  well-formed 
nipple,  it  should  be  placed  at  the  mother's  breast  regularly 
at  three-hour  intervals  on  the  second  day,  for  two-  or 
three-  minute  periods,  even  though  there  is  little  hope 
of  the  breasts  secreting  at  this  time.  By  this  means  the 
infant  is  trained  to  expect  its  food  at  regular  periods, 
and  at  the  same  time  the  maternal  breast  is  stimulated. 
When  a  wet-nurse  can  be  supplied  in  the  home  who  has 
her  own  infant  with  her,  the  latter  can  be  used  to  stimu- 
late the  breasts  of  the  mother,  and  the  new  infant  can 
have  one  of  the  wet-nurse's  breasts  set  aside  for  its  use. 
Where  the  infant  is  very  weak,  the  breast  set  aside  for  it 
can  be  made  to  secrete  more  freely  by  simultaneously 
placing  the  wet-nurse's  baby  on  the  opposite  breast  dur- 
ing the  period  of  nursing. 

We  have  found  this  to  be  a  very  valuable  expedient. 
However,  with  this  latter  method  of  procedure  the  quan- 
tity taken  by  the  premature  infant  must  be  accurately 
measured  to  prevent  overfeeding  by  weighing  the  in- 
(84) 


FEEDING   PREMATURE   INFANTS.  85 

fant  before  and  after  the  nursing  period.  Nursing  di- 
rectly from  the  breast  has  the  added  advantage  of  de- 
veloping the  baby's  sucking  muscles,  preventing  con- 
tamination of  the  milk,  and  stimulating  the  breasts  by 
the  natural  method.  It  should,  however,  be  remembered 
that  a  weak  infant  may  nurse  the  maternal  breast  for  a 
considerable  time,  and  yet  the  amount  of  food  taken  may 
be  insufficient.  This  is  especially  true  of  that  class  of  in- 
fants who  are  inclined  to  go  to  sleep  at  the  breasts.  Here, 
again,  weighing  is  of  the  utmost  importance.  When  the 
infant  is  too  weak  to  nurse  sufficiently  to  satisfy  its 
needs,  as  ascertained  by  weighing,  the  nursing  should  be 
followed  by  substitute  feeding  with  expressed  milk,  either 
by  the  bottle  or  one  of  the  other  methods  to  be  described. 
These  rules  do  not  apply  for  the  first  and  second  day, 
when  only  rarely  more  than  four  or  five  meals  should  be 
given.  In  very  weak  infants,  and  those  subject  to  re- 
gurgitation  after  taking  small  quantities  of  milk,  it  may 
be  necessary  to  feed  more  frequently  in  periods  varying 
from  two  to  two  and  a-half  hours,  as  may  be  indicated 
by  the  quantity  retained,  or  better  results  may  be  obtained 
by  catheter  feeding  (to  be  described  later)  with  four- 
hour  intervals. 

2.  Infants  Too  Weak  to  Nurse  the  Breasts. 

In  this  class  of  infants,  wherever  possible,  they  should 
be  fed  without  being  removed  from  their  bed  or  the  in- 
cubator, if  used,  so  as  to  avoid  all  careless  exposure  of 
the  infant.  The  cause  of  inability  to  nurse  may  be  due 
to  several  factors:  (1)  Infants  unable  to  swallow;  this 
is  usually  because  of  improper  development  of  the  center 
in  the  medulla,  or  lack  of  co-ordination  on  the  part  of 
the  pharyngeal  muscles  and  tongue.  This  is  usually  made 
evident  by  the  milk  flowing  from  the  dependent  part  of 
the  mouth.  In  such  cases  it  is  generally  necessary  to  re- 
sort to  catheter  feeding.  (2)  Those  too  weak  to  nurse, 


86  INFANT   FEEDING. 

and  who  may  appear  to  be  almost  dead ;  in  this  class  there 
is  great  danger  in  handling  the  infant,  and  it  is  best  fed 
in  the  bed.  (3)  Those  who  will  not  suck.  (4)  Those 
vomiting  after  every  feeding.  (5)  Those  becoming 
cyanotic  after  feeding.  In  the  latter  cases  it  may  even  be 
necessary  to  resort  to  such  methods  as  gentle  friction, 
artificial  respiration,  best  performed  by  gently  compress- 
ing the  thorax,  warm  baths,  oxygen,  etc. 

Methods.    One  of  the  following  methods  can  be  s,e- 
lected  for  feeding  these  infants: 

1.  The  nasal  spoon,  which  can  be  used  either  by  pour- 
ing the  milk  slowly  into  the  nose  or  into  the  mouth.    The 
latter  is  to  be  preferred,  because  of  the  dangers  due  to 
decomposition  of  the  milk  in  the  nose  and  naso-pharynx, 
with  secondary  development  of  rhinitis  and  pharyngitis. 

2.  A   medicine  dropper  for  mouth  feeding.     This  is 
possibly  one  of  the  best  methods  for  feeding  this  class 
of  infants,  as  it  is   simple  of  application,  and  a  small 
dropper  is  easily  obtainable.    As  in  all  other  methods,  the 
food  should  be  administered  very  slowly. 

3.  Nursing  From  a  Bottle.    For  this  purpose  the  small 
nipples  commonly  sold  on  doll  nursing-bottles  are  of  the 
proper  size,  and  can  usually  be  obtained  of  proper  quality. 
We  have  not  infrequently  perforated  the  rubber  end  of 
a  medicine  dropper  and  used  it  for  this  purpose.     The 
bottle  to  be  used  can  either  be  an  ordinary  1-ounce  or  2- 
ounce  medicine  bottle,  or,  better,  the  special  bottle  which 
was  designed  by  the  author  for  this  purpose.    This  bottle 
holds  2  ounces  of  milk,  is  graduated  in  cubic  centimeters, 
has  a  ground  glass  neck  which  coapts  perfectly  with  the 
bulb  on  the  special  breast-pump,  and  which  after  being 
filled  is  corked  with  a  ground  glass  stopper,  and  which 
has  the  added  advantage  in  that  the  milk  is  in  no  way 
handled  after  it  leaves  the  breast. 

4.  The  Breck  Feeder.    This  has  the  added  advantage 
that  the  milk  can  be  passed  into  the  pharynx  without 
effort  on  the  part  of  the  child  when  it  is  too  weak  to 


FEEDING   PREMATURE   INFANTS. 


87 


nurse.    This  has  the  one  disadvantage  of  too  rapid  feed- 
ing if  not  properly  controlled. 

5.  A  rather  slow  but  satisfactory  method  of  feeding 
the  infants  is  by  expressing  the  milk  directly  from  the 
nipple  into  the  infant's  mouth  during  the  feeding  period. 


Fig.  5. — Breck  feeder  for  premature  infants. 

6.  Catheter  Feeding  by  Mouth  (gavage).  For  this 
purpose  a  small  funnel  is  attached  either  directly  or  by 
means  of  a  short  piece  of  rubber  tubing  with  a  glass 
connection  to  rubber  catheter.  A  Nelaton  catheter  is 
used  (best  a  No.  12  French),1  about  25  to  40  cm.  long 
(10  to  16  inches),  marked  in  centimeters  or  inches,  so 


1  No.  12  French — No.  8    American — No.  5  English.    Diameter — 
4  mm. 


gg  INFANT   FEEDING. 

that  at  all  times  its  position  can  be  estimated.  The  in- 
fant should  be  fed  in  the  incubator,  its  crib,  or  on  the 
dressing  table.  Its  head  should  be  slightly  lower  than 
the  body.  The  passage  of  the  catheter  is  usually  effected 
without  difficulty  by  grasping  it  as  one  would  a  pen,  and 
passing  it  in  the  midline  to  the  pharynx,  gradually  push- 


Fig.  6. — Apparatus  for  gavage  and  lavage. 

ing  it  into  the  esophagus.  This  is  usually  accomplished 
without  difficulty,  because  of  the  poorly  developed 
pharyngeal  reflexes,  and  rarely  results  in  retching  or 
vomiting.  In  infants  who  retch  during  the  passage  of 
the  catheter,  vomiting  may  be  expected  because  of  the 
fact  that  these  latter  infants  not  infrequently  belong  to 
the-  spasmophilic  group.  The  danger  of  passing  the 
catheter  into  the  larynx  is  minimal.  It  is  rarely  necessary 
to  pass  the  catheter  more  than  10  centimeters  (4  inches) 


FEEDING    PREMATURE    INFANTS. 


89 


beyond  the  infant's  lips,  and  we  have  found  it  equally  as 
practical  to  limit  the  passage  of  the  catheter  to  7.5  centi- 
meters (3  inches).  In  most  instances  this  does  not  reach 
the  stomach,  but  has  the  added  advantage  of  preventing 


Fig.  7. — Feeding  baby  with  catheter. 

trauma  to  the  cardiac  end  of  the  stomach  and  the  gas- 
tric mucosa.  When  a  graduated  catheter  is  not  at  hand, 
it  may  be  marked  at  10  centimeters  with  indelible  ink, 
and  this  used  as  the  maximum  point  for  passage.  A 
fairly  safe  maximum  for  the  passage  of  the  catheter  can 
be  ascertained  by  measuring  the  distance  from  the  glab- 


90  INFANT   FEEDING. 

ella  to  the  epigastrium  in  the  individual  infant.  The  de- 
sired quantity  of  milk  is  allowed  to  flow  into  the  stom- 
ach, slowly,  by  raising  the  funnel  only  very  slightly  above 
the  level  of  the  body.  After  feeding,  the  catheter  is 
firmly  compressed  to  avoid  all  leakage  into  the  pharynx, 
and  the  catheter  then  removed,  but  not  too  rapidly.  The 
milk  to  be  fed  should  be  measured  in  a  graduated  glass, 
and  the  latter  kept  close  at  hand  in  order  that  the  amount 
given  can  at  all  times  be  estimated. 

A  complete  record  of  every  feeding,  both  as  to  the 
time  and  the  amount,  should  be  kept.  This  is  especially 
important  in  institutions  where  the  nurses  have  a  number 
of  infants  to  observe,  and  is  greatly  facilitated  by  a  time- 
clock  registering  the  day,  hour,  and  minute  of  each  feed- 
ing. The  nurse  records  the  quantity  of  milk  taken,  which 
in  breast-fed  infants  is  obtained  by  weighing  the  infant 
both  before  and  after  feeding  on  an  accurate  scale,  or  in 
infants  too  weak  to  nurse  by  measuring  the  quantity  in 
a  graduated  glass  before  feeding. 

3.  Proper  Time  for  Beginning  Regular  Feeding. 

Due  to  the  tendency  toward  the  rapid  development  of 
acute  inanition  in  this  class  of  infants,  the  greatest  dan- 
ger is  that  of  too  long  delay  in  establishing  regular  feed- 
ing. Therefore  it  is  often  impossible  to  wait  for  the 
mother's  milk  to  appear.  We  believe  that  it  is,  however, 
unwise  in  most  instances  to  attempt  to  feed  with  milk 
during  the  first  twelve  to  twenty-four  hours,  rather  pre- 
ferring to  allow  the  circulatory  and  respiratory  organs 
opportunity  for  proper  accommodation  to  their  new  en- 
vironment. During  this  time  the  loss  of  body  fluids 
through  evaporation  from  the  skin  and  respiratory  tract 
due  to  the  warmth  of  the  incubator,  and  the  excretions 
through  the  kidneys  and  bowels,  should  be  recompensed 
by  the  regular  administration  of  water  or  some  other 
inert  fluid. 


FEEDING   PREMATURE   INFANTS.  91 

We  endeavor  to  administer  by  the  tenth  day  about  one- 
sixth  of  the  body  weight  of  water  (inclusive  of  that 
contained  in  the  milk  if  given)  in  twenty-four  hours. 

In  smaller  infants  the  first  milk  is  given  diluted  one 
or  two  times  during  the  first  four  days.  After  the  first 
twenty-four  hours  water  can  be  administered  partly  with 
the  food,  and  otherwise  between  feedings.  If  for  any 
reason  the  water  is  not  well  retained  when  given  by 
mouth,  it  can,  at  least  in  part,  be  administered  by  rectum. 
Example :  An  infant  weighing  about  1200  grams  should 
receive  200  mils  of  water;  should  this  infant  receive  50 
mils  of  milk,  this  can  be  diluted  with  50  mils  or  more  of 
water  or  sugar  solution,  and  the  remaining  100  mils  ad- 
ministered between  feedings. 

If  a  stimulant  is  indicated,  a  few  drops  of  brandy  (6 
to  15  in  twenty-four  hours)  may  be  added  to  the  water 
or  sugar  solution  during  the  first  twenty-four  hours. 
Half  strength  of  Ringer's  solution  prepared  as  follows 
can  be  used  to  very  good  advantage  for  rectal  adminis- 
tration : 

NaCl   7.5  Gm. 

KC1  0.1     " 

CaCl   0.2     " 

Water  1000.0  mils. 

We  have  made  it  a  rule  never  to  start  milk  feeding 
until  after  the  first  bowel  movement.  Not  infrequently 
the  removal  of  meconium  may  be  accomplished  by  the 
administration  of  a  small  quantity  of  physiological  salt 
solution  through  a  catheter  passed  one  or  two  inches 
into  the  rectum.  This  is  done  to  remove  the  meconium 
before  infection  of  the  intestinal  tract  through  the 
administration  of  food.  Occasionally  it  is  necessary 
to  administer  5  drops  of  castor  oil  to  obtain  slight 
purgation. 


92  INFANT   FEEDING. 

4.  Feeding  From  the  Second  to  the  Tenth  Day. 

It  must  be  remembered  that  the  general  rules  as  ap- 
plied to  the  feeding  of  premature  infants  do  not  hold 
for  the  first  ten  days  of  life.  The  early  feedings  must 
necessarily  be  small,  and  the  increases  gradual.  Two 
grave  dangers  present  themselves  during  the  first  period 
of  the  infant's  existence:  (1)  overfeeding  and  (2)  star- 
vation, the  latter  usually  resulting  from  an  inability  to 
supply  sufficient  quantity  of  human  milk,  following  an 
attempt  to  await  the  natural  secretion  of  the  mother's 
breast.  Overfeeding  results  either  in  vomiting  or,  more 
seriously,  in  stomach  distention,  which  leads  to  asphyxia 
and  cyanosis.  Underfeeding  in  these  weak  infants  soon 
leads  to  inanition.  From  the  second  day  these  infants 
should  be  fed  regularly  day  and  night,  every  two  or, 
better,  three  hours,  depending  upon  the  infant's  condition 
and  the  method  of  food  administration.  Not  infre- 
quently where  the  quantities  taken  are  very  small,  ten  to 
twelve  feedings  are  required  in  twenty-four  hours.  It 
may  even  be  necessary  in  very  weak  infants  to  feed 
minimal  quantities  every  hour. 

The  question  of  the  number  of  feedings  will  be  dis- 
cussed in  detail  later. 

It  is  practically  impossible  to  formulate  definite  rules 
for  feeding  premature  infants  during  the  first  ten  days, 
because  of  their  great  variation  in  weight  and  develop- 
ment. Therefore  it  becomes  necessary  to  feed  each  in- 
fant individually. 

During  the  first  days  it  is  often  difficult  in  infants 
weighing  1000  to  1200  grams  or  less  to  feed  more  than 
20  to  50  mils  of  milk  per  day,  and  it  may  be  necessary  to 
limit  the  food  to  this  quantity  during  the  first  ten  days. 
It  is  our  rule  to  start  feedings  in  this  class  of  cases  with 
a  maximum  of  4  mils  per  feeding,  not  infrequently  using 
one-fourth  or  one-half  human  milk  at  the  start,  and  the 
balance  water. 


FEEDING   PREMATURE   INFANTS.  93 

The  feedings  should  be  increased  by  1  mil  at  a  time, 
and  with  the  first  evidence  of  regurgitation  the  quantity 
should  remain  stationary.  Even  in  favorable  cases  dur- 
ing this  time  30  to  50  calories  per  kilogram  is  likely  to 
be  the  maximum  that  can  be  fed  with  impunity. 

The  small  feedings  which  can  be  assimilated,  and  the 
low  energy  quotient  during  the  first  two  or  three  weeks, 
must  be  considered  physiological,  and  as  we  rarely  see 
an  increase  in  weight  with  feedings  of  less  than  90  cal- 
ories per  kilogram,  we  are  confronted  by  a  rapid  loss  in 
body  weight  during  the  first  days  of  life.  In  favorable 
cases  this  is  usually  followed  by  a  stationary  weight,  or 
moderate  fluctuations  after  the  first  four  to  seven  days. 
Occasionally  an  infant  is  seen  in  whom  there  is  sufficient 
water  retention  to  avoid  most  of  the  initial  loss  in  weight. 
One  should,  therefore,  remember  that  even  with  fre- 
quent feedings  with  human  milk,  either  at  the  breast,  by 
hand,  or  gavage,  it  is  rarely  possible  to  feed  more  than 
the  minimum  requirements  without  causing  vomiting. 

5.  Feeding  After  the  First  Ten  Days. 

There  has  been  considerable  discussion  as  to  the  food 
requirements  of  premature  and  underweight  infants 
during  the  past  few  years.  Budin  gives  us  the  rule  that 
premature  infants  of  less  than  2500  grams  after  their 
tenth  day  require  one-fifth  of  their  body  weight  (200 
Gm.  per  kilogram  of  body  weight),  or  140  calories,  while 
the  full-term  infant  of  normal  development  requires  one- 
seventh  of  its  body  weight  (140  Gin.  per  kilogram  body 
weight),  or  100  calories  per  day.  On  the  other  hand, 
Birk  believes  that  the  more  fully  developed  premature 
infant,  and  those  nearing  the  normal,  will  thrive  on  one- 
sixth  to  one-seventh  of  their  body  weight. 

Our  opinion,  based  on  a  series  of  experiments  made 
on  a  number  of  premature  infants,  is  that  they  require 
higher  food  values,  or  at  least  the  maximum  required  by 


94  INFANT   FEEDING. 

normal  infants,  for  the  following  reasons:  (1)  the 
greater  body  surface  as  compared  with  the  body  weight ; 
(2)  in  the  normal  infant  the  requirements  decrease  with 
the  age,  and  therefore  in  the  premature  the  quantity  re- 
quired varies  inversely  with  the  fetal  age  after  the  first 
weeks  of  life;  (3)  the  need  for  body  development  is 
relatively  greater  in  the  premature  than  in  the  full-term 
infant;  (4)  a  kilogram  of  body  weight  in  the  fat-poor 
premature  infant  cannot  be  taken  as  parallel  in  feeding 
to  the  well  developed  full-term  infant,  with  its  prepon- 
derance of  fatty  tissue.  This  latter  point  must  also  be 
considered  in  the  feeding  of  the  marasmic  infant,  to 
obtain  a  proper  gain  in  weight  as  compared  with  the 
lower  requirements  in  the  fat,  full-term  infant. 

6.  Number  of  Feedings  Daily. 

Our  own  experience  has  led  us  to  adopt  a  conservative 
position  in  that  we  have  grouped  the  infants  nursed  at 
the  breast  or  fed  from  the  bottle  or  by  feeders  into  two 
general  classes:  (1)  those  weighing  under  1500  Gm., 
and  (2)  those  above  this  figure,  based  on  the  tendency 
of  the  smaller  infants  to  become  exhausted  when  the 
feedings  are  long  continued.  The  former  are  fed  at  2- 
hour  intervals  during  the  day,  and  3-hour  intervals  at 
night,  as  follows:  6  A.M.,  8  A.M.,  10  A.M.,  12  M.,  2  P.M., 
4  P.M.,  6  P.M.,  9  P.M.,  12  P.M.,  and  3  A.M. — 10  feedings 
during  the  twenty-four  hours.  The  larger  infants  are 
fed  on  a  3-hour  basis,  8  feedings  being  given  during  the 
twenty-four  hours.  These  figures  should  in  no  way  be 
construed  as  arbitrary.  All  feedings  are  more  or  less 
dependent  upon  the  general  development  of  the  infant  in 
relation  to  its  digestion  and  metabolism,  its  retention, 
and  upon  the  larger  quantities  of  food  necessarily  given 
to  meet  its  nutritional  requirements,  and  a  careful  atten- 
tion to  gastric  distention,  regurgitation,  asphyxia,  cya- 
nosis, and  other  respiratory  complications. 


FEEDING   PREMATURE   INFANTS.  95 

It  has  been  our  personal  experience  to  meet  with  con- 
siderable difficulty  in  attempting  to  meet  the  large  food 
requirements  in  smaller  infants  without  resorting  to 
catheter  feeding.  In  these  we  have  adopted  the  longer 
interval  between  feedings,  of  four  hours  with  six  feed- 
ings in  twenty-four  hours,  the  individual  meal  in  catheter 
feeding  being  greater  in  quantity.  Notwithstanding  the 
fact  that  catheter  feeding  offers  little  difficulty  and  few 
dangers  in  experienced  hands,  this  may  not  be  true  with 
those  not  skilled  in  its  use.  A  considerable  number  of 
our  cases  have,  however,  thrived  satisfactorily  on  quan- 
tities of  milk  less  than  one-fifth  of  their  body  weight  per 
day,  and  one  should  always  remember  that  it  is  a  safe 
axiom  not  to  force  the  feeding  in  these  cases  as  long  as 
their  general  development  is  progressing  satisfactorily 
and  their  weight  curve  is  good. 

7.  The  Amount  of  Each  Feeding. 

The  statistics  as  to  the  stomach  capacity  for  food  in 
premature  infants  indicate  that  this  varies  within  con- 
siderable limits,  even  in'infants  of  the  same  fetal  age,  as 
does  also  their  ability  to  digest  and  assimilate  food. 
The  weight  and  length,  naturally  excluding  congenital 
diseases  and  deformities,  will  be  far  more  dependable  as 
a  guide  to  stomach  capacity  than  the  fetal  age.  As  no 
definite  rules  can  be  established  governing  the  amounts 
of  individual  feedings,  we  begin  with  what  could  be 
considered  minimum  quantities  and  gradually  increase 
the  amount  of  feedings  as  the  infant  develops  an  ability 
to  digest  it.  It  is  our  rule,  as  previously  stated,  during 
the  first  few  days  to  feed  small  total  quantities  varying 
from  20  to  50  mils  of  milk  per  day,  dividing  these  totals 
by  the  number  of  feedings  to  be  administered  (eight  to 
ten),  thereby  feeding  from  2  to  6  mils  of  milk  per  feed- 
ing. The  feedings  can  then  be  increased  by  1  or  more 
mils  at  a  time,  and  in  the  absence  of  vomiting  the  in- 
dividual feedings  can  be  increased  more  or  less  rapidly 


96  INFANT   FEEDING. 

until  the  weight  loss  ceases  or  an  increase  in  weight  oc- 
curs. Even  in  favorable  cases,  weighing  over  1500  Gm., 
75  to  150  mils  per  kilogram  weight  (50  to  100  calories  per 
kilogram)  is  likely  to  be  the  maximum  that  can  be  fed 
with  impunity  or  safety  during  the  first  ten  days. 

8.  Daily  Gains. 

These  are  not  necessarily  in  proportion  to  the  changing 
quantity  of  milk  administered,  as  many  factors,  such  as 
condition  of  the  bowels,  quantity  of  the  urine  passed, 
temperature  of  the  infant's  surroundings,  will  neces- 
sarily influence  the  weight.  This  is  more  especially 
noticeable  in  observations  continued  during  a  short  period 
of  time.  An  average  greater  daily  gain  than  20  Gm. 
is  unusual  when  the  infant's  food  is  limited  to  one-fifth 
of  its  body  weight.  An  average  of  from  10  to  20  Gm. 
daily  can  in  most  cases  be  considered  satisfactory. 

9.  Artificial  Feeding. 

There  can  be  no  comparison  between  the  results  to  be 
expected  in  feeding  premature  infants  on  human  milk, 
and  those  to  be  obtained  with  artificial  food.  With 
human  milk  taken  from  a  well  regulated  department  for 
wet-nurses  the  milk  can  be  obtained  fresh,  practically 
sterile;  it  is  more  digestible;  its  constituents  are  of  the 
quality  and  in  the  proportions  required  for  the  growth 
and  development  of  the  human  body;  and  it  is  live,  and 
contains  many  of  the  immunity-conferring  properties,  as 
evidenced  by  the  resistance  of  a  breast-fed  infant  to  in- 
fections and  contagious  diseases.  Most  of  these  proper- 
ties and  advantages  are  lacking  in  the  dead  foods  used 
in  artificial  feeding.  Therefore,  if  it  becomes  necessary 
to  resort  to  artificial  feeding,  the  selection  of  the  food, 
its  preparation,  and  its  adaptation  to  the  infant  must  all 
be  given  the  most  painstaking  consideration.  Many 
varieties  of  artificial  diet  have  been  suggested  by  various 


FEEDING   PREMATURE   INFANTS.  97 

authors,  such  as  simple  milk  dilutions,  cream  and  top- 
milk  mixtures,  skim  and  buttermilk  mixtures,  malt  soup 
preparations,  condensed  and  evaporated  milk,  etc.  The 
results  with  the  various  diets  are  to  a  great  degree  de- 
pendent upon  the  physician's  intimate  understanding  of 
and  directions  for  the  use  of  the  individual  food. 

Quantity  of  Food.  It  must  be  remembered  that  the 
figures  quoted  for  feeding  on  breast  milk  are  the  maxi- 
mum that  can  be  assimilated,  and  in  most  instances  these 
amounts  more  than  fulfil  the  immediate  needs  of  the 
infant's  existence,  and  can  be  considered  (and  in  most 
instances  would  be)  excessive  quantities  for  artificial 
feeding  in  the  first  few  weeks  of  life,  because  of  the 
greater  difficulty  in  the  digestion  of  cow's  milk.  One 
hundred  calories  per  kilogram  is  the  maximum  quantity 
that  can  be  digested  by  most  premature  infants,  and  in 
many  instances  one  must  be  satisfied  with  a  sustaining 
diet  bordering  on  70  to  80  calories,  and  they  must  at  all 
times  be  closely  watched  for  evidence  of  overfeeding,  as 
it  is  dangerous  to  exceed  the  actual  food  requirements, 
and  the  first  evidence  of  digestive  disturbances  or  of  in- 
tercurrent  infections  should  lead  to  the  feeding  of  human 
milk.  During  the  first  days  the  same  rules  for  minimal 
feedings  must  be  observed  as  in  feeding  with  breast  milk. 

Quality  of  Food.  Opinions  vary  greatly  as  to  the 
best  food  for  an  artificial  diet.  Ordinary  milk,  water 
and  sugar  mixtures  are  rarely  well  taken.  Pfaundler  sug- 
gests rich  fat  and  low  protein  milk  mixtures ;  but  in  this 
feeding  we  have  seen  fat  diarrhea  resulting.  Budin  ob- 
tained the  best  results  with  peptonized  boiled  milk,  using 
fresh  pancreatic  extracts  for  this  purpose.  Finkelstein, 
Oberwarth,  Birk,  Neumann,  Von  Reuss  have  obtained 
their  best  results  through  the  use  of  boiled  buttermilk 
mixtures,  prepared  according  to  the  following  formulae: 

Buttermilk  or  skim  milk 1000 

Flour  (dcxtrinized)   10 

Sugar  (cane)   40 

The  above  being  used  for  the  first  feedings. 
1 


98  INFANT   FEEDING. 

Buttermilk  or  skim  milk 1000 

Flour  (dextrinized)   15 

Sugar  (cane)   60 

For  later  feedings. 

Maltose-dextrin  compounds  can  be  substituted  for  the 
cane-sugar  if  desirable. 

Chymogen  or  pegnin  milk  has  given  us  most  satis- 
factory results  in  the  artificial  feeding  of  the  premature 
infants.  This  latter  preparation  is  little  more  than 
a  boiled  milk  in  which  the  curds  are  precipitated  in 
a  fine,  flocculent  form,  about  the  size  of  that  of  human 
milk,  before  it  is  fed  to  the  infant.  It  is  best  diluted  be- 
fore use.  This  preparation  should  be  started  with  1  part 
chymogen  milk  and  3  parts  water,  following  the  direc- 
tions for  increases  in  quantity  and  quality  as  given  for 
human  milk.  Because  of  the  low  carbohydrate  content 
of  such  mixtures,  0.5  per  cent,  of  lactose  should  be 
added  after  the  first  few  days,  and  the  amount  gradually 
increased  to  3  per  cent. 

When  even  only  insufficient  amounts  of  human  milk 
can  be  obtained,  artificial  feeding  should  be  used  as  a 
supplement  and  not  as  a  substitute. 

10.  Conclusions. 

1.  The   weight,   temperature,    stools,    absence   of    ab- 
dominal distention,  cyanosis  and  well-being  of  the  infant 
should  be  the  guide  for  increase  in  the  infant's  diet. 

2.  The  utmost  care  is  necessary  in  increasing  the  diet 
of  the  infant  during  the  first  days  of  life.    The  gastro- 
intestinal tract  offers  the  best  evidence   for  increases. 
Vomiting  and  abdominal  distention  and  associated  cya- 
nosis are  the  prime  indications   for  stationary   or   de- 
creased amounts  of  feeding. 

3.  An  initial  weight  loss  during  the  first  ten  days  must 
be  considered  physiological. 


FEEDING   PREMATURE   INFANTS.  99 

4.  These  infants,  therefore,  should  be  fed  small  quan- 
tities, frequently  repeated,  every  two  to  three  hours  dur- 
ing the  day  and  night. 

5.  After  the  first  twelve  hours  human  milk  may  be  fed 
diluted  with  one  or  two  parts  of  water  and  sugar,  with 
a  caloric  value  approximating  15  to  30  calories  (20  to  40 
mils,  %  to  1%  ounce  of  human  milk  to  the  kilogram  of 
body  weight). 

6.  From  the  second  day  on,  in  the  absence  of  indiges- 
tion, the  food  may  be  increased  by  10  calories  daily  per 
kilogram  (15  mils  daily  per  kilogram).    In  the  presence 
of  digestive  disorders  greater  care  is  necessary  to  main- 
tain the  metabolic  equilibrium    (120  mils,  4  ounces  of 
milk  to  the  kilogram  of  body  weight). 

7.  It  is  of  the  greatest  importance  to   administer  a 
sufficient  supply  of  water  to  counterbalance  the  rapid 
evaporation  due  to  artificially  heated  and  dried  air,  and 
the  excessive  excreta,  more  especially  during  the  first 
few  days.    About  one-sixth  of  the  body  weight  of  water, 
inclusive  of  that  contained  in  the  milk,  should  be  fed  in 
twenty-four  hours  by  the  tenth  day. 

8.  It  is  to  be  remembered  that  a  standstill  in  the  weight- 
curve,  and  indigestion  with  bad  bowel  movements,  fre- 
quently result  when  200  mils  (140  calories)  per  kilogram 
are  exceeded. 

9.  All    intestinal    disturbances    in    premature    infants 
should  be  given  the  utmost  consideration. 

10.  The  method  of  administration  of  food  in  each  case 
varies  with  the  vitality  of  the  infant. 

11.  In   all   cases   of   prematurity,   syphilis   should   be 
thought  of;  and  in  cases  in  which  there  is  the  slightest 
suspicion,  the  infant  must  not  be  placed  directly  on  the 
breast  of  a  wet-nurse. 


PART  III. 
Artificial  Feeding. 


CHAPTER    I. 

RECENT   PROGRESS   IN   ARTIFICIAL 
FEEDING. 

THE  presentation  of  the  subject  of  artificial  feeding 
without  a  review  of  the  progress  and  evolution  which 
our  ideas  on  this  subject  have  undergone  during  the  past 
years  might  easily  mislead  the  student  to  the  belief  that 
the  last  word  in  artificial  feeding  of  infants  has  been 
said.  The  men  who  have  given  this  subject  the  most  con- 
sideration, we  believe,  would  agree  that  much  is  to  be 
hoped  for  in  the  future  in  artificial  feeding. 

It  is  most  difficult  to  present  in  a  concise  manner  the 
best  that  we  have  learned  in  artificial  feeding  so  that  it 
may  be  practically  applied,  because  of  two  very  important 
factors  which  make  for  success:  (1)  a  careful  interpre- 
tation of  the  needs  of  the  individual  infant,  and  (2)  ex- 
perience on  the  part  of  the  feeder  to  meet  those  needs. 

It  remained  for  the  American  school  of  pediatrics  to 
do  the  pioneer  work  in  placing  artificial  feeding  on  a 
scientific  basis. 

Pepper  and  Meigs,  of  Philadelphia,  gave  us  the  first 
rational  method  in  milk  modification.  They  more  espe- 
cially attempted  to  vary  the  percentages  of  casein  in 
cow's  milk,  believing  that  the  excessive  quantity  con- 
tained in  cow's  milk  was  in  great  part  the  cause  of  feed- 
ing difficulties.  This  was  accomplished  by  diluting  the 
milk  and  adding  milk-sugar  and  cream  to  make  up  the 
deficiency  in  energy  value. 
(100) 


PROGRESS    IN    ARTIFICIAL   FEEDING.  101 

Rotch,  of  Boston,  made  further  advances  in  infant 
feeding  in  that  he  taught  us  that  fat  and  sugar,  as  well 
as  protein,  were  important  factors  in  the  disturbances  of 
the  artificially  fed  infants.  His  work  on  percentage  feed- 
ing, whereby  he  increased  or  decreased  the  various  con- 
stituents of  human  milk  to  meet  definite  clinical  pictures, 
was  probably  the  first  epoch-making  advance  in  infant 
feeding,  and  his  system  of  feeding  has  since  been  known 
as  "the  percentage  method"  of  infant  feeding. 

The  German  school,  of  which  Rubner  and  Heubner 
were  the  chief  advocates,  gave  us  the  so-called  "caloric 
method"  of  feeding,  by  which  they  sought  to  provide  the 
number  of  heat  units  required  by  the  infant,  basing  their 
estimations  on  the  infant's  weight.  Of  this  method  we 
will  have  occasion  to  speak  later.  It  is  sufficient  to  state 
that  we  do  not  now  use  this  as  a  method  of  feeding,  but 
find  a  check  on  the  caloric  contents  of  the  food  of  in- 
estimable value  in  determining  the  value  of  our  mixtures 
in  avoiding  over-  and  under-  feeding.  The  German 
school  have  never  attempted  the  refinements  in  the  per- 
centage composition  of  their  mixtures  as  advocated  by 
the  American  school. 

More  recently  Czerny  and  Finkelstein  have  taught  us 
the  dangers  of  overfeeding  with  whole  milk,  and  also  its 
individual  ingredients,  fat,  sugar,  and  salts,  individually 
and  in  combination.  Their  studies  have,  on  the  whole, 
ignored  the  proteins,  in  all  probability  due  to  the  fact 
that  protein  disturbances  other  than  those  seen  in  infants 
suffering  from  an  idiosyncrasy  to  cow's  milk  are  for  the 
most  part  limited  to  infants  fed  on  raw  cow's  milk, 
while  most  of  the  Continental  clinics  have  for  several 
years  fed  boiled  milk.  Their  studies  and  conclusions  will 
be  more  fully  discussed  under  the  disturbances  of  arti- 
ficially fed  infants. 

During  the  past  few  years  there  has  been  an  increased 
tendency  to  boil  cow's  milk  before  feeding  to  the  infants 
in  American  clinics,  based  On  the  desire  to  render  the 


102  INFANT   FEEDING. 

curd  more  fragile,  and  at  the  same  time  to  destroy  the 
pathogenic  bacterial  content  of  the  milk.  While  this  has 
many  advantages,  it  must  not  be  forgotten  that  it  must 
necessarily  cause  changes,  more  especially  in  the  fer-. 
ments,  vitamines,  and  salts,  which  are  of  vital  importance 
to  human  economy.  The  ferments  are  believed  to  be  im- 
portant to  the  infant,  and  this  importance  has  been  em- 
phasized especially  since  the  introduction  of  pasteuriza- 
tion and  boiling  of  milk,  for  the  reason  that  a  high  degree 
of  heat  destroys  them.  Some  of  the  ferments  are  normal ) ' 
constituents  of  milk,  such  as  lipase,  galactase,  lacto-  j 
kinase,  and  diastase.  The  absence  of  ferments  in  the,1 
milk  indicates  that  it  has  been  heated.  Hamburger's 
studies  on  the  biologic  differences  in  human  and  cow's 
milk  are  unquestionably  of  vast  importance,  and  though 
there  has  been  a  tendency  in  recent  years  to  neglect  this 
factor  in  infant  feeding,  we  believe  that  it  will  again 
receive  more  important  recognition  in  the  near  future. 
The  changes  caused  in  milk  by  boiling  make  it  necessary 
to  administer  fruit  and  vegetable  juices,  non-dextrinized 
cereals,  and  other  foods,  such  as  codliver  oil,  to  prevent 
the  retarded  development  on  the  part  of  the  infant. 


CHAPTER    II. 
COW'S   MILK. 

No  method  of  artificial  feeding  can  perfectly  replace 
nursing  or  human  milk  feeding.  This  must  be  admitted, 
notwithstanding  the  many  advances  that  have  been  made 
in  infant  feeding  during  recent  years. 

When  breast  feeding  is  impracticable  feeding  with 
properly  modified  milk  of  other  animals  is  necessary. 
Although  cow's  milk  shows  marked  chemical,  physical 
and  biological  differences  from  human  milk,  for  practical 
reasons  it  has  been  found  to  be  the  one  best  suited  for 
this  purpose. 

How  Cow's  Milk  Differs  from  Maternal  Milk.  The 
differences  between  these  two  milks  summarized  in  a 
table  which  follows  are  greater  than  the  table  indicates. 
While  cow's  milk  may  be  modified  to  approximate 
woman's  milk  in  composition,  it  can  never  be  just  the 
same  or  just  as  good  for  infants. 

Cow's  milk  is  more  opaque  than  human  milk,  although 
the  latter  may  contain  a  greater  percentage  of  fat.  This 
is  due  to  the  opacity  of  the  calcium-casein,  which  is  pres- 
ent in  greater  proportion  in  cow's  milk.  Cow's  milk  is 
faintly  acid  or  amphoteric  when  freshly  drawn,  but  ordi- 
narily is  distinctly  acid  in  reaction  when  consumed. 
Human  milk  is  amphoteric  or  alkaline. 

There  is  three  times  as  much  protein  in  cow's  milk  as 
in  human  milk.  The  reason  for  this  is  obvious,  when  we 
recall  that  the  ratio  of  the  growth  of  the  calf  to  that  of 
the  infant  is  about  as  2:  1.  Furthermore,  the  protein  in 
cow's  milk  consists  chiefly  of  casein  (3.02  per  cent.)  and 
little  lactalbumin  (0.53  per  cent.),  while  human  milk  con- 
tains 0.59  per  cent,  of  casein  and  1.23  per  cent,  lactal- 
bumin. The  sugar  in  the  two  milks  varies  greatly  in 

(103)  ' 

® 


I 


104  INFANT   FEEDING. 

amount,  but  not  in  kind.  Cow's  milk  contains  almost 
four  times  the  amount  of  inorganic  salts  compared  to 
woman's  milk.  In  cow's  milk  calcium  and  magnesium 
are  in  greater  proportion,  while  in  woman's  milk  potas- 
sium and  sodium  bases  are  in  relatively  greater  amounts. 
These  differences  have  an  important  bearing  upon 
infant's  metabolism.  There  is  no  great  difference  in  the 
average  amount  of  fat  in  the  two  milks;  however,  both 
in  human  milk  and  in  cow's  milk  the  fat  is  the  most 
variable  constituent. 

The  curd  from  cow's  milk  is  usually  tougher  and  in 
larger  masses  than  in  human  milk.  There  are  also  dif- 
ferences in  antibodies,  ferments,  etc. 

Cow's  Milk  Human  Milk 

Amphoteric  or  acid     Reaction    Amphoteric     or     alk- 
aline 

1.029  to  1.034  ........  Sp.  gr 1.010  to  1.040 

3.5  per  cent Proteins  1.5  to  2.0  per  cent. 

3.02  per  cent Caseinogen    0.5  to  0.75  per  cent. 

0.53  per  cent Lactalbumin    1.23  per  cent. 

Clots  in  large  lumpy 

curds    Effect  of  rennin Clots  in  fine  curds 

4.0  per  cent Fat   3.5  to  4.0  per  cent. 

4.5  per  cent Lactose    6.0  to  7.0  per  cent. 

0.75  per  cent Salts    0.2  per  cent. 

13  to  14  per  cent.  . . .  Total  solids  12  to  13  per  cent. 

86  to  87  per  cent.  . . .  Water  86  to  88  per  cent. 

Never  sterile   Bacterial  contents   ...Practically  sterile 

Biedert,  whose  theory  found  many  followers  at  one 
time,  believed  that  casein  of  the  cow's  milk  was  the  dis- 
turbing factor  in  artificial  feeding. 

The  large,  tough  curds  forming  from  the  casein  of  raw 
cow's  milk  differ  considerably  from  the  fine  flocculent 
curds  of  the  human  milk  casein.  Steps  have  been  taken 
to  make  the  cow's  milk  curd  resemble  the  human  milk 
curd  in  its  physical  properties,  such  as  boiling  the  milk, 
citration  and  addition  of  cereal  waters,  and  it  was  found 
that  this  modification  considerably  improved  the  results 
of  artificial  feeding. 


COW'S   MJLK.  105 

The  differences  in  the  fat  contents  of  the  two  milks 
have  less  frequently  been  drawn  upon  for  explanation  of 
frequent  nutritional  disturbances  on  artificial  feeding, 
although  it  has  positively  been  established  that  fat  plays 
an  important  part  in  the  nutritional  disturbances  of  the 
artificially  fed  infant.  The  butter  prepared  from  cow's 
milk  contains  10  per  cent,  of  volatile  acids,  while  that 
prepared  from  the  human  milk  only  1.5  per  cent.  And 
especially  the  irritant  butyric  acid  glycerid,  which  is  con- 
tained in  6  per  cent,  in  butter  prepared  from  cow's  milk, 
is  contained  only  in  traces  in  human  milk.  The  fat  drops 
of  cow's  milk  are  also  on  the  whole  much  larger  than 
those  of  human  milk. 

Lactose  is  the  principal  sugar  in  both  cow's  and  human 
milk,  average  human  milk  containing  6  to  7  per  cent., 
and  cow's  milk  4  to  5  per  cent.  This  increased  sugar 
(  contents  of  the  human  milk,  with  its  fermentation,  ac- 
counts for  the  laxative  effect  of  breast  milk  feeding  when 
the  milk  is  abundant. 

L.  F.  Meyer  has  experimentally  shown  that  salts  of  the 
cow's  milk,  which  vary  both  quantitatively  and  qualita- 
tively from  those  of  human  milk,  have  unfavorable  in- 
fluence on  children  with  nutritional  disturbances.  While 
we  cannot  from  these  experiments  conclude  that  the  same 
holds  true  for  normal,  healthy  children,  yet  we  have  to 
admit  that  the  salt  contents  of  the  two  milks  are  of  great 
importance  in  artificial  feeding. 

Escherich  and  Hamburger  were  of  the  opinion  that 
human  milk  contained  ferments  which  favorably  influ- 
enced the  processes  of  metabolism.  Salge  found  that 
tetanus  and  diphtheria  antitoxins  could  be  utilized  by  the 
infant  only  when  fed  in  human  milk,  while  when  con- 
tained in  the  milk  of  other  species  they  did  not  get  into 
the  body  fluids  of  the  infant.  But  whether  these  biologic 
differences  are  of  great  importance  to  the  infant  remains 
to  be  proven. 


106  INFANT   FEEDING. 

Although  it  seems  probable,  yet  it  has  not  been  demon- 
strated that  cow's  milk  feeding  taxes  the  digestive  func- 
tions of  the  infant's  organism  more  than  human  milk 
feeding. 

Of  great  importance  is  the  bacterial  contents  of  the 
milk,  the  human  milk  being  either  sterile  or  of  low  bac- 
terial contents,  while  cow's  milk  is  never  sterile,  and  not 
infrequently  its  bacterial  content  is  very  high.  Steril- 
ized, pasteurized,  and  certified  milk  were  the  practical  re- 
sults of  the  efforts  to  obtain  germ-free  milk  for  infant 
feeding. 

The  milk  for  infant  feeding  must  come  from  healthy 
cows,  must  be  obtained  in  clean  manner  into  clean  re- 
ceptacles, must  be  cooled  very  soon  after  milking  in  order 
to  keep  down  the  bacterial  content,  and  kept  cool  after- 
wards. It  must  be  delivered  to  the  consumer  as  soon 
as  possible  in  such  a  way  as  to  prevent  any  contamina- 
tion, and  must  be  handled  in  the  home,  cleanly,  in  sterile 
receptacles,  and  at  all  times  be  kept  cool. 

The  cow  from  which  the  milk  is  obtained  must  be 
entirely  healthy,  and  be  especially  free  from  tuberculosis 
and  glanders,  tuberculin  and  mallein  test  being  advisable 
as  a  routine,  besides  general  examination  of  the  cow. 
The  cows  must  be  kept  clean,  in  a  clean  stable,  which 
is  well  ventilated  and  drained.  No  dust,  manure,  or  fod- 
der, except  that  used  for  immediate  feeding,  should  be 
kept  in  the  stable.  The  cows  should  be  kept  clean,  but 
even  then  they  should  be  cleaned  again  immediately  be- 
fore milking. 

The  milking  must  be  done  in  a  clean  way  and  milk 
kept  clean  afterwards,  in  order  that  the  bacterial  count 
may  be  as  low  as  possible.  Dry  feeding  of  the  cows  is 
preferable,  since  on  this  feeding  the  feces  is  less  liquid, 
and  cows  can  be  kept  clean  with  less  difficulty.  The 
milkers  should  be  free  from  any  communicable  disease, 
and  be  of  clean  habits.  The  udders  of  the  cows  and  the 
hands  of  the  milker  should  be  scrubbed  with  warm 


COW'S   MILK.  107 

water  and  soap  immediately  before  milking,  and  anti- 
septic solution  may  be  applied  afterwards.  Milking 
should  be  done  into  covered  cans,  and  milk  made  to  pass 
through  a  filter  first.  The  cans  should  be  always  cleaned 
immediately  after  the  milk  is  poured  out,  first  with  cold 
and  then  with  hot  water,  and  also  rinsed  out  with  hot 
water  before  milking.  The  first  few  ounces  of  milk 
should  be  discarded,  since  this  milk  contains  large 
amounts  of  bacteria  that  are  washed  out  from  the  ex- 
cretory ducts. 

Cooling  the  milk  after  it  is  obtained  is  a  very  impor- 
tant step  in  the  production  of  clean  milk.  The  milk  hav- 
ing been  obtained  with  the  above-described  precautions, 
with  as  few  bacteria  as  possible,  should  be  cooled  at 
once  in  order  to  prevent  growth  and  multiplication  of 
the  bacteria  that  have  entered  the  milk  in  spite  of  all  the 
precautions.  This  is  accomplished  by  special  cooling  ap- 
paratuses, or  simply  by  pouring  the  milk  into  sterilized 
bottles,  closing  with  sterilized  cap,  and  putting  on  ice. 
The  milk  in  bottles  should  be  kept  iced  until  it  reaches 
the  consumer,  which  should  not  take  longer  than  twenty- 
four  hours. 

In  the  home  precautions  should  be  taken  to  prevent 
additional  contamination,  and  to  keep  the  milk  iced  to 
prevent  further  growth  of  bacteria,  until  everything 
necessary  is  ready  for  making  the  proper  mixture  for  in- 
fant feeding.  Many  good  milks  are  spoiled  on  the  door- 
step of  the  home  between  the  hour  of  delivery  and  plac- 
ing the  milk  in  the  ice-box.  All  the  utensils  and  vessels 
used  for  preparing  the  mixture  must  be  perfectly  clean 
and  sterilized  by  boiling.  As  soon  as  the  mixture  is  made 
it  should  be  put  into  the  ice-box  again  and  kept  there, 
portions  being  taken  during  the  day  for  individual  feed- 
ings, and  warmed  separately  just  before  feeding. 

Certified  Milk.  The  term  "certified  milk"  was  coined 
by  Dr.  Henry  L.  Coit,  of  Newark,  N.  J.,  who  in  1892, 
needing  good  milk  for  his  own  baby,  formulated  a  plan 


108  INFANT   FEEDING. 

for  the  production  of  clean,  fresh,  pure  milk  under  the 
auspices  of  a  medical  milk  commission.  The  term  "cer- 
tified milk,"  then,  is  the  milk  of  the  highest  quality,  of 
uniform  composition,  obtained  by  cleanly  methods  from 
healthy  cows,  under  the  special  supervision  of  a  medical 
milk  commission. 

The  use  of  the  term  "certified  milk"  should  be  limited 
to  milk  produced  in  accordance  with  the  requirements  of 
the  American  Association  of  Medical  Milk  Commission- 
ers. The  first  requisite  in  the  production  of  certified 
milk  is  to  enlist  the  co-operation  of  a  trustworthy  dairy- 
man who  enters  into  a  contract  with  the  medical  milk 
commission.  In  accordance  with  the  terms  of  this  con- 
tract, the  dairyman  binds  himself  to  comply  with  the 
specifications  set  forth,  in  return  his  milk  is  certified. 

The  dairies  are  subjected  to  periodic  inspections,  and 
the  milk  to  frequent  analyses.  The  cows  producing  cer- 
tified milk  must  be  free  from  tuberculosis,  as  shown  by 
the  tuberculin  test  and  physical  examination  by  a  quali- 
fied veterinarian,  and  from  all  other  communicable  dis- 
ease, and  from  all  diseases  and  conditions  whatsoever 
likely  to  deteriorate  the  milk.  They  must  be  housed  in 
clean,  properly  ventilated  stables  of  sanitary  construc- 
tion, and  must  be  kept  clean  and  properly  fed  and  cared 
for.  All  persons  who  come  in  contact  with  the  milk  must 
exercise  scrupulous  cleanliness,  and  must  not  harbor  the 
germs  of  typhoid,  tuberculosis,  diphtheria,  or  other  in- 
fections liable  to  be  conveyed  by  the  milk.  Milk  must  be 
drawn  under  all  precautions  necessary  to  avoid  contam- 
ination, and  must  be  immediately  cooled,  placed  in  steril- 
ized bottles,  and  kept  at  a  temperature  not  exceeding  50° 
F.,  until  delivered  to  the  consumer.  Pure  water,  as  de- 
termined by  chemical  and  bacteriological  examination,  is 
to  be  provided  for  use  throughout  the  dairy  farm  and  the 
dairy.  Certified  milk  should  not  contain  more  than  10,- 
000  bacteria  per  cubic  centimeter,  and  should  not  be  more 
than  thirty-six  hours  old  when  delivered. 


COW'S   MILK.  109 

Inspected  Milk.  This  term  should  be  limited  to 
clean,  fresh  milk  from  healthy  cows,  as  determined  by 
the  tuberculin  test  and  physical  examination  by  a  quali- 
fied veterinarian.  The  cows  are  to  be  fed,  watered, 
housed,  and  milked  under  good  conditions,  but  not  neces- 
sarily equal  to  those  prescribed  in  the  production  of  cer- 
tified milk.  Scrupulous  cleanliness  must  be  exercised  and 
particular  care  be  taken  that  persons  having  communi- 
cable diseases  do  not  come  into  contact  with  the  milk. 
This  milk  must  be  delivered  in  sterilized  containers,  and 
kept  at  a  temperature  not  exceeding  50°  F.  until  it 
reaches  the  consumer.  There  should  be  not  more  than 
100,000  bacteria  per  cubic  centimeter  of  inspected  milk. 
This  milk  should  be  pasteurized. 

Market  Milk.  All  milk  that  is  not  certified  or  in- 
spected in  accordance  with  the  above  definitions,  and  all 
milk  that  is  of  unknown  origin,  is  classed  as  "market 
milk,"  and  should  be  pasteurized. 

Frozen  Milk.  In  our  own  experience  we  have  found 
that  many  infants  were  made  ill  by  feeding  of  raw  frozen 
milk  which  has  been  rapidly  thawed,  and  allowed  to 
stand  in  a  warm  room.  Not  infrequently  vomiting  and 
diarrhea  result.  These  symptoms  are  obviated  when  the 
milk  is  boiled.  Pennington  and  her  collaborators  found 
very  definite  changes  in  milk  after  freezing.  They  found 
that  when  the  milk  is  held  at  a  temperature  of  0°  C.  there 
is  proteolysis  of  the  casein,  which  is  primarily  of  bacterial 
origin,  and  proteolysis  of  the  lactalbumin,  due  primarily 
to  the  native  enzymes  of  the  milk.  The  action  of  these 
two  agents  together  is  more  rapid  than  that  of  either 
alone.  The  bacteria  and  enzymes  may  break  down  the 
true  protein  and  carry  the  breaking  down  through  to  pep- 
tones, even  to  amino-acids.  There  is  a  fermentation  of 
lactose  with  the  formation  of  lactic  acid,  which  is  largely, 
if  not  exclusively,  due  to  bacterial  action.  The  fat,  so  far 
as  can  be  determined,  is  not  affected  except  by  the  action 
of  bacteria. 


110  INFANT   FEEDING. 

Mixed  Milk  Versus  Milk  of  One  Cow.  It  is  far  bet- 
ter, other  things  being  equal,  to  use  the  mixed  milk  of  a 
herd  in  preparing  a  baby's  food  than  the  milk  of  one 
cow,  because  if  the  milk  comes  from  one  cow,  and  the 
cow  is  ill  in  any  way,  the  baby  is  almost  certain  to  be  dis- 
turbed, whereas  if  one  or  two  cows  in  a  herd  are  ill,  the 
milk  from  these  cows  will  be  so  diluted  that  the  baby  will 
probably  not  notice  it.  On  the  other  hand,  it  is,  or  should 
be,  self-evident  that  the  milk  of  a  healthy  cow  properly 
fed  and  properly  cared  for,  taken  in  the  proper  way,  and 
kept  under  proper  conditions,  is  better  than  the  mixed 
milk  of  a  herd  which  is  improperly  fed,  and  whose  milk 
is  not  carefully  obtained  or  carefully  taken  care  of. 

Boiling,  Sterilization,  and  Pasteurization.  Before 
entering  into  a  discussion  of  this  subject,  it  is  only  fair 
io  state  that  the  general  teaching  in  America  of  feeding 
/with  raw  milk  has  led  to  the  production  of  safe,  clean 
j  certified  milk  in  the  large  communities  where  so  many 
'  fatalities  were  experienced  through  the  feeding  of  un- 
clean milk.  Any  methods  of  handling  milk  which  will  in 
the  least  interfere  with  the  proper  production  of  clean 
milk,  and  lead  to  the  feeling  that  unclean  milk  can  be 
made  safe  for  infant  feeding  by  the  application  of  heat  or 
other  methods,  would  be  a  backward  step  in  infant  feed- 
ing, and  would  necessarily  cause  dire  results.  While  the 
European  countries,  as  Germany  and  France,  have  ad- 
vocated feeding  boiled  milk  for  many  years  without  fear 
of  bad  nutritional  disturbances  due  to  the  changes  in  the 
milk,  in  America  feeding  with  raw  milk  has  until  re- 
cently been  favored.  Increased  experience  with  boiled 
milk,  especially  by  those  who  have  long  used  raw  milk, 
leads  to  the  growing  conviction  that  boiled  milk  is  more 
easily  digested  than  raw  milk  by  dyspeptic  infants,  and 
hence  by  the  well  infants. 

While  we  do  not  believe  that  feeding  with  boiled  milk 
should  be  advised  as  a  general  measure,  when  it  is  pos- 
sible to  obtain  a  good  certified  milk,  and  when  the  latter 


COW'S   MILK.  HI 

is  to  be  placed  in  the  hands  of  mothers  and  nurses  who 
can  be  depended  upon  to  keep  the  milk  clean  and  whole- 
some through  proper  icing  and  handling,  we  do  believe 
that  when  these  requirements  cannot  be  met,  that  it  is 
safer  even  in  well  babies  to  feed  a  thoroughly  sterilized 
milk,  and  that  this  can  be  done  without  danger  of  de- 
velopment of  scurvy  and  rickets,  when  these  feedings  are 
accompanied  by  the  administration  of  fruit  juices,  vege- 
table soups,  and  purees  and  codliver  oil. 

Brennemann  suggests  that  we  must  answer  the  follow- 
ing questions  before  deciding  as  to  whether  we  should 
feed  raw,  pasteurized,  or  boiled  milk: 

(1)  Does   raw   milk   offer  advantages  over  boiled 

milk? 

(2)  Does  boiled  milk  offer  advantages  over  raw 

milk? 

(3)  Does  pasteurization  solve  the  problem? 

(4)  Does  certified  milk  solve  the  problem? 

In  answer  to  the  first  question  we  must  decide  whether 
the  changes  caused  in  milk  by  boiling,  such  as  partial 
coagulation  of  lacto-albumin,  caramelization  of  some  of 
the  milk-sugar,  its  action  on  casein,  inhibiting  coagula- 
tion with  rennin,  etc.,  lessen  the  nutritive  value  of  cow's 
milk  as  an  infant  food.  We  believe  that  the  sentiment  of 
American,  German,  and  French  clinics,  in  whkh  boiled 
milk  has  been  used  for  a  long  period  of  time,  is  on  the 
whole,  most  favorable  to  boiled  milk,  with  its  lesser 
dangers. 

Constipation  has  been  suggested  as  an  argument 
against  boiling  milk.  We  believe  that  constipation  in  the 
bottle-fed  baby  is  one  of  the  safest  earmarks  of  the  well- 
being  of  the  infant,  and  that  only  that  constipation  which 
is  due  to  excessive  feeding  of  fat,  with  too  little  car- 
bohydrate, and  which  will  be  later  described,  is  an  ex- 
ception to  this  statement.  While  with  raw  milk  digestive 
disturbances  are  frequently  seen  before  sufficient  milk  is 
given  to  properly  nourish  the  infant,  this  is  far  less  com- 


112  INFANT   FEEDING. 

mon  with  boiled  milk;  in  fact,  it  has  not  infrequently 
been  our  experience  that  we  have  overfed  with  boiled 
milk,  because  the  infant  handles  it  to  so  much  better 
advantage.  In  digestive  disturbances,  with  loose  stools, 
it  is  digested  to  much  better  advantage  than  raw  milk, 
which  frequently  results  in  formation  of  hard  casein 
curds  as  well  as  fat  curds.  The  assertion  that  feeding 
with  boiled  milk  results  in  anemia,  underdevelopment  and 
rickets,  we  believe,  is  not  well  founded,  and  these  condi- 
tions, when  present,  are  due  to  other  causes.  Scurvy  de- 
veloping during  the  course  of  feeding  with  boiled  milk 
has  never  been  seen  in  our  experience,  except  when  some 
of  the  proprietary  infant  foods  have  been  fed  in  con- 
junction with  boiled  milk.  That  under  certain  conditions 
scurvy  should  develop  in  presence  of  long-continued  feed- 
ing with  boiled  milk  alone,  is  not  to  be  denied.  The  dan- 
gers, however,  are  very  remote,  as  testified  to  by  the 
German  and  French  clinicians.  When  such  dangers  are 
feared,  they  can  easily  be  overcome,  as  previously  sug- 
gested, by  the  feeding  of  fresh  fruit  juices  and  vegetable 
preparations  together  with  the  milk  diet. 

Does  boiled  milk  offer  advantages  over  raw  milk? 
Boiled  milk  when  properly  handled  is  relatively  free 
from  pathogenic  micro-organisms,  and  if  the  milk,  which 
has  been  boiled,  was  clean  milk,  also  from  their  toxic 
products. 

Boiling  in  the  home  has  the  great  advantage  over  com- 
mercial pasteurization  in  that,  if  the  milk  is  raw  and 
spoiled  before  it  reaches  the  home,  this  can  readily  be 
detected  by  the  housewife.  While  we  know  that  certain 
pathogenic  organisms  may  develop  in  the  milk  without 
giving  evidence  of  their  presence,  and  cause  formation 
of  toxic  bodies  which  are  not  removed  by  boiling  in  the 
home,  the  latter  process  still  offers  every  advantage  over 
commercial  pasteurization.  Boiling  milk  in  the  home  will 
most  certainly  remove  the  dangers  from  infection  with 
tuberculosis,  scarlet  fever,  streptococcus  sore  throat,  ty- 


COW'S   MILK.  113 

phoid  fever,  dysentery,  and  many  other  milk-borne  dis- 
eases. The  advantages  of  boiled  milk  in  the  presence  of 
indigestion  and  diarrhea  have  already  been  mentioned. 
The  small,  flocculent  curd  of  the  boiled  milk  is  also  rapidly 
and  more  easily  digested  than  the  large,  tough  casein 
curds  of  the  raw  milk.  The  hard  bean-like  protein  curds 
are  never  seen  in  stools  of  the  infant  fed  on  milk 
which  has  been  thoroughly  boiled,  although  we  have  oc- 
casionally seen  them  in  overfeeding  with  cow's  milk  which 
has  been  heated  by  the  double  boiler  process.  These  latter 
cases,  however,  are  exceptions. 

7  Larger  amounts  and  more  concentrated  mixtures  of 
boiled  milk  can  be  fed  than  in  feeding  with  raw  milk. 
This  is  a  distinct  advantage  in  the  beginning  of  the  feed- 
ing of  atrophic  infants.  This  latter  advantage  is  not  to 
be  overlooked.  While  the  large  percentage  of  healthy 
babies  will  apparently  digest  equally  well  raw  and  boiled 
milk  within  therapeutic  limits,  it  will  be  found  that  most 
authors  who  do  not  resort  to  heating  milk  will,  at  least  in 
some  other  way,  modify  the  curd  of  raw  cow's  milk, 
either  by  simple  dilution,  by  the  use  of  cereal  waters  or 
an  alkaline,  such  as  lime  water  or  sodium  citrate.  We 
agree  with  Brennemann  in  his  statements  that  boiling 
commends  itself  as  an  excellent  casein  modifier,  and  that 
it  effectually  disposes  of  the  majority  of  bacteriological 
problems  when  the  milk  is  properly  handled  after  boiling. 
Pasteurization  versus  Boiling.  Pasteurization  was 
first  recommended  because  of  the  belief  that  boiled  milk 
has  scorbutic  properties,  which  could  not  be  laid  at  the 
door  of  pasteurized  milk.  The  question  of  the  relation- 
ship between  boiled  milk  and  scurvy  has  already  been 
touched  upon.  Pasteurization  in  the  home  is  not  a  very 
satisfactory  process.  Commercial  pasteurization,  even 
though  properly  carried  out,  is  too  distant  from  the 
probable  time  of  consumption  of  the  food  to  be  a  safe 
measure,  unless  the  milk  is  properly  handled  after  pas- 
teurization. The  best  argument  presented  by  the  advo- 

8 


114  INFANT   FEEDING..^ 

cates  of  pasteurization  is  that  the  milk  is  essentially  a 
raw  milk  in  so  far  as  its  physiological  properties  are 
concerned. 

Certified  Milk  versus  Boiling.  Clean  certified  milk, 
properly  handled,  both  before  and  after  it  reaches  the 
home,  and  where  the  cost  is  not  prohibitive,  when  well 
digested  by  the  individual  infant,  still  remains  the  ideal 
food  for  artificial  feeding.  When  these  requirements 
cannot  be  met,  boiling  in  the  home  is  the  best  method 
for  preparation  of  milk  for  the  infant. 

Various  Methods  of  Boiling  Milk.  In  our  own  work 
we  have  resorted  in  most  cases  to  the  heating  of  the 
milk  in  a  double  boiler.  This  has  several  advantages  in 
that  the  milk  is  heated  in  a  closed  vessel,  and  has  then  a 
less  pronounced  flavor  than  when  heated  in  open  ves- 
sels, and  causes  but  little  pellicle  formation,  unless  we 
have  a  very  thin  column  of  milk.  To  overcome  this  lat- 
ter, we  therefore  recommend  the  smallest  double  boiler 
which  can  be  obtained,  and  which  will  at  the  same  time 
hold  all  of  the  milk  which  is  to  be  prepared.  The  milk 
mixture  is  put  in  the  inner  receptacle,  cold,  and  the  water 
in  the  outer  vessel  also  cold.  The  double  boiler  is  then 
placed  on  the  stove,  and  allowed  to  remain  until  the 
water  in  the  outer  vessel  boils  for  six  to  eight  minutes. 
While  the  milk  heated  in  this  manner  forms  a  very  much 
finer  and  softer  curd  than  that  of  raw  milk,  it  is  not  as 
fine  as  that  of  milk  boiled  directly  over  the  flame.  How- 
ever, in  most  cases,  it  answers  all  purposes,  and  has 
the  advantages  above  enumerated.  In  the  presence  of 
gastric  and  intestinal  indigestion  and  allied  conditions, 
the  finer  curd  of  the  milk  boiled  directly  over  the  flame 
may  be  more  suitable;  and  in  exceptional  cases,  when 
boiling  over  the  direct  flame  for  three  to  five  minutes  does 
not  give  the  desired  result,  milk  boiled  for  30  to  45 
minutes  over  the  direct  flame  will  offer  further  advan- 
tages, and  this  method  is  worthy  of  trial  for  temporary 
use. 


CHAPTER    III. 

ADAPTATION    OF    MILK    FOR   INFANT 
FEEDING. 

FROM  the  foregoing  it  may  be  seen  that  there  is  no  per- 
fect substitute  for  human  milk  in  the  feeding  of  the  in- 
fant, and  therefore  every  effort  should  be  made  to  assist 
the  mother  in  the  nursing  of  her  infant. 

Since  all  the  attempts  made  to  feed  an  infant  on  the 
food  not  primarily  intended  for  this  purpose  are  at- 
tempts at  milk  adaptation,  we  necessarily  know  that  no 
single  method  can  possibly  meet  the  needs  of  all  infants. 

And  therefore  it  must  be  our  object,  first,  to  formulate 
our  rules  so  as  to  make  them  safe  and  adaptable  to  the 
feeding  of  the  majority  of  well  babies,  leaving  the  dis- 
cussion of  exceptional  and  sick  babies  for  further  study. 
It  must  necessarily  go  without  saying  that  the  food 
recommended  will  be  excessive  for  some  and  inadequate 
for  others.  Every  organism  has  its  individuality  and  its 
fixation  coefficient,  and  every  infant  makes  a  different  use 
of  the  food  administered  to  it.  All  infants  cannot,  there- 
fore, be  treated  according  to  the  same  rule. 

While  many  excellent  results  have  been  reported  with 
the  various  methods  described  for  artificial  feeding  of  in- 
fants, and  some  attempt  has  been  made  to  place  feeding 
on  a  scientific  basis,  we  believe  that  we  must  concede 
that  the  methods  are  all  more  or  less  empirical,  and  the 
result  will  be  in  considerable  degree  dependent  upon  the 
wide  range  of  food  tolerance  of  the  healthy  infant.  The 
successful  physician  must  depend  on  the  clinical  ob- 
servation of  the  individual  infant  for  the  success  of  the 
method  of  feeding  which  he  is  using.  Every  formula 
with  which  we  start  feeding  should  be  looked  upon  in 
the  light  of  an  experiment,  and  the  reaction  of  the  infant 
to  this  feeding  should  be  carefully  studied. 

(115) 


116  INFANT   FEEDING. 

If  these  principles  are  borne  in  mind,  many  an  ob- 
stacle to  successful  infant  feeding  will  be  avoided. 

We  believe  that  the  attempts  toward  ultra  refinement 
of  the  infant's  diet  has  led  to  considerable  confusion,  be- 
cause of  the  different  conclusions  of  the  various  schools 
undertaking  the  work.  Eventually,  however,  infant  feed- 
ing will  be  placed  on  a  thoroughly  scientific  basis.  This, 
however,  does  not  answer  the  pressing  needs  of  to-day, 
which  call  for  a  safe  and  practical  solution  of  the  feed- 
ing problem  for  the  everyday  baby  in  everyday  life.  The 
parents  commonly  receive  feeding  advice  from  baby- food 
manufacturers;  and  if  feeding  on  one  preparation  is  not 
successful,  there  is  a  rapid  transition  from  one  proprietary 
baby  food  to  another,  with  untold  detriment  to  the  infant. 
In  advancing  the  rules  for  feeding  the  normal  healthy  in- 
fant, with  further  suggestions  for  the  underfed,  on  simple 
milk  mixtures  with  carbohydrates  added,  we  desire  to 
state  that  in  our  clinical  experience  we  have  found  them 
safe  for  the  baby  and  practical  for  the  physician,  which 
latter  is  neither  to  be  overlooked  nor  taken  lightly. 

We  claim  nothing  original  for  these  feeding  sugges- 
tions, as  they  represent  the  more  common  practice  of  the 
Continent,  and  America  as  well.  We  have,  however, 
formulated  the  rules  which  govern  the  application  of 
simple  milk  mixtures,  with  carbohydrates  added,  in  such 
a  way  that  their  application  becomes  more  practical. 
Knowing  that  the  advice  herein  given  is  founded  on 
clinical  experience,  and  that  similarly  good  clinical  re- 
sults have  been  obtained  by  others  by  various  methods, 
we  believe  it  advisable  to  briefly  review  the  more  popular 
methods  of  infant  feeding  as  practiced  today. 

Undiluted  Whole  Milk.  While  undiluted  milk  has 
been  used  with  varying  degrees  of  success  by  some 
German  and  French  pediatricians  (of  the  latter  Budin 
being  the  foremost  advocate),  it  may  be  generally  stated 
that,  on  the  whole,  it  is  not  well  borne  before  the  fourth 
month  of  life.  If  whole  boiled  milk  is  used  in  the  feed- 


MILK  FOR   INFANT   FEEDING.  117 

ing  of  the  very  young  infant,  the  size  of  the  individual 
meal  must  be  greatly  restricted  over  that  as  recommended 
for  diluted  mixtures,  so  that  it  will  not  exceed  the  caloric 
requirements  of  the  individual.  Budin  recommended 
that  all  whole  milk  fed  to  an  infant  should  first  be  boiled, 
which  causes  the  protein  to  be  precipitated  in  the  infant's 
stomach  in  the  form  of  a  fine  curd.  This  can  be  fur- 
ther facilitated  by  the  addition  of  pegnin  or  chymogen, 
which  causes  the  formation  of  the  fine  curds  before  it  is 
fed  to  the  infant,  with  no  recoagulation  in  the  stomach.1 
Alkalinizing  milk  by  the  addition  of  sodium  bicarbonate 
also  results  in  the  formation  of  fine  curds.  In  some 
forms  of  vomiting,  small  quantities  of  a  concentrated 
food  will  frequently  be  found  of  considerable  value.  As 
a  routine  measure  of  feeding,  whole  milk  cannot  be 
recommended. 

The  Percentage  Method  or  System  of  Feeding.  This 
is  frequently  spoken  of  as  the  American  method,  or 
Rotch's  method,  because  of  the  fact  that  Rotch,  of  Bos- 
ton, did  much  to  popularize  and  systematize  this  method 
of  feeding.  Not  only  did  he  work  out  a  system  of 
formulae  adapted  to  infants  of  varying  ages  and  develop- 
ment, but  he  also  was  the  means  of  establishing  the  first 
so-called  public  milk  laboratory.  The  chief  objections 
to  this  method,  as  originally  described  by  Rotch,  were 
'  its  lack  of  flexibility  and  the  difficulty  of  remembering  the 
various  formulae  and  their  preparation.  The  followers  of 
the  Rotch  school  state  that  the  percentage  feeding,  so- 
called,  is  not  a  method  of  feeding,  but  merely  a  method 
of  calculation,  and  a  means  of  obtaining  relative  accuracy 
in  the  preparation  of  infants'  foods.  They  have  sim- 
plified the  method  as  originally  applied,  lengthened  the 
feeding  intervals,  still  retaining  some  of  the  original  ideas. 
It  has  to  a  large  extent  been  replaced  by  the  simpler 
methods  of  milk  modification. 


1  Brennemann,  Archives  of  Pediatrics,   1917,  34,  81. 


118  INFANT    FEEDING. 

Top  Milk  Feeding.  In  this  method  a  definite  number 
of  ounces  of  the  upper  part  of  the  milk,  which  has  stood 
for  a  number  of  hours,  is  used  as  the  basis  for  preparing 
the  mixture  to  be  fed. 

To  successfully  carry  out  top  milk  feeding,  the  per- 
centages of  fat  at  various  levels  in  32  ounces  (quart)  of 
milk  containing  4  per  cent,  of  fat,  and  which  has  stood 
for  six  hours  or  longer,  must  be  known : 

Upper  16  oz.  has  7  per  cent.  fat. 
"      20    "     "    6    " 
a       04    "     "    5    "        "        " 

(1)  This  method  endeavors  to  provide  ample  caloric 
values.  In  this  respect  the  method  may  be  regarded  as 
successful.  (2)  There  is  the  idea  that  casein  is  not 
very  digestible,  and  that  it  is  advantageous  to  feed  casein 
in  small  quantities,  making  up  the  shortage  in  energy 
value  of  the  mixture  with  fat.  In  the  light  of  our  pres- 
ent knowledge,  however,  we  know  that  the  casein  of 
boiled  or  alkalinized  milk,  or  when  mechanically  divided 
by  the  addition  of  cereals,  is  easily  digested.  (3)  The 
attempt  to  produce  a  formula  with  the  percentage  of  fat 
in  the  same  proportion  as  is  found  in  human  milk,  as 
well  as  larger  amounts,  which,  however,  frequently  leads 
to  fat  indigestion,  because  of  the  greater  difficulty  experi- 
enced by  many  infants  in  handling  large  quantities  of 
cow's  milk  fat.  (4)  The  importance  of  the  sugar  and 
salt  content  of  the  mixture  is  underestimated. 

This  method  of  feeding,  nevertheless,  has  many  ad- 
vocates, and  we  would  advise  that  the  above  shortcom- 
ings of  the  method  as  originally  described  be  given  full 
consideration  by  those  adopting  this  method  of  feeding. 


CHAPTER    IV. 

MILK    DILUTIONS    WITH    THE    ADDITION 
OF    CARBOHYDRATES. 

IT  has  been  our  experience  that  about  90  per  cent,  of 
the  infants  that  come  under  our  observation  for  artificial 
feeding  will  tolerate  a  wide  range  of  quantitative  values 
in  the  components  of  the  milk,  i.e.,  fats,  proteins,  carbo- 
hydrates, and  salts.  And  the  simpler  the  first  formula 
on  which  the  baby  is  started,  the  easier  we  find  it  to 
meet  its  later  needs  for  growth  and  development,  by  in- 
creasing or  decreasing  the  individual  elements  in  the  diet. 
The  first  step  of  this  method  consists  in  the  dilution  of 
whole  milk  with  water,  thereby  reducing  all  the  ingredi- 
ents of  the  milk.  When  we  compare  such  a  dilution  with 
human  milk  we  find  that  when  protein  approximates  that 
contained  in  breast  milk,  the  fat  is  considerably  reduced 
below  that  contained  in  the  latter.  This  in  practical  feed- 
ing we  find  to  be  an  advantage  rather  than  a  disadvan- 
tage, and  if  there  be  an  indication  for  increasing  the  fat 
content  of  the  formula  this  is  easily  accomplished  by  the 
addition  of  cream,  or  top  milk,  which  is,  however,  usu- 
ally not  necessary,  as  the  deficiency  in  fat  can  usually  be 
successfully  compensated  by  adding  sugar  and  starch 
to  the  formula.  As  a  result  of  dilution,  the  salts,  which 
are  about  three  times  as  great  in  quantity  in  cow's  milk, 
are  reduced  to  more  nearly  the  amounts  contained  in 
breast  milk.  We  must,  however,  remember  that  there  are 
qualitative  differences  in  the  salt  content  of  the  cow's 
milk  dilution  and  human  milk  (page  144). 

Feeding  should  primarily  be  formulated  to  promote 
normal  growth  and  development,  to  supply  energy  for  the 
body  functions,  to  prevent  disease;  and,  although  of  no 
lesser  importance,  feeding  in  disease  should  be  given  a 
secondary  consideration  in  the  study  of  this  subject. 

(119) 


120  INFANT   FEEDING. 

The  food  must  be  given  in  such  form  that  the  infant 
may  be  able  to  digest  it  easily,  to  assimilate  it,  and 
to  utilize  its  constituents  for  the  purposes  enumerated 
above. 

The  following  factors  must  be  considered  before  esti- 
mating the  composition  and  quantity  of  food  for  infant 
feeding. 

1.  The    clinical    aspects — that    is,    the    general    well- 
being  of  the  infant — must  be  given  equal   importance 
with    the    percentage    and    energy    value    of    the    food 
administered. 

2.  Is  there  a  normal  gain  in  weight  which  an  infant 
must  show  as  a  sign  of  full  health? 

3.  The  qualitative  and  quantitative  chemical  composi- 
tion of  the  food,  the  number  of  calories  available  from 
the  total  administered,  and  the  proportion  of  the  total 
fixated  in  the  body  must  be  taken  into  calculation. 

The  normal  artificially  fed  infant  should  manifest  the 
same  clinical  evidences  of  good  health  and  progress  as 
are  seen  in  the  breast-fed  infant.  It  should  be  com- 
fortable, which  he  manifests  in  a  happy  disposition.  He 
should  be  a  good  sleeper,  and  awaken  regularly  for  his 
feedings,  and  there  should  be  no  more  occasion  for  his 
crying  than  in  the  case  of  the  breast-fed  baby.  His  tem- 
perature should  show  maximum  excursions  of  1°  to  2°  F. 
daily.  He  should  have  large  quantities  of  subcutaneous 
fat,  and  his  muscular  tissue  should  be  well  developed. 
The  turgor  of  his  tissues  should  be  normal.  The  latter 
can  be  estimated  by  the  eye  and  by  palpation.  The 
muscles  may  be  taken  between  the  fingers,  and  their  firm- 
ness or  softness  estimated  in  this  way.  By  raising  a  fold 
of  the  skin  we  may  determine  whether  the  panniculus 
adiposus  is  well  developed.  The  stools,  which  of  neces- 
sity must  vary  with  the  diet,  are  firmer  and  drier  and 
much  paler  than  those  of  the  breast-fed  infant,  and  he 
should  pass  one  or  two  daily.  Except  in  the  presence  of 
large  amounts  of  carbohydrates,  ancl  mgre  especially  malt 


MILK  DILUTIONS  WITH  CARBOHYDRATES.       121 


sugars,  they  are  alkaline  in  reaction,  and  have  a  foul 
odor. 

Therefore,  we  see  that  the  criterion  of  good  health  for 
the  artificially  fed  infant  depends  on  many  things, 
which  together  make  up  the  condition  of  the  infant.  And 
we  again  desire  to  emphasize  that  the  impression  of  the 
general  well-being  of  the  infant  is  a  much  safer  method 
of  estimating  its  progress  than  a  study  of  his  weight- 
curve  alone. 


Fig.  8. — Scale  for  weighing  infants. 

We  have  learned  to  recognize  the  study  of  the  infant's 
iveight  as  one  of  the  simplest  and  most  reliable  clinical 
factors  in  estimation  of  the  infant's  progress.  And  while 
of  necessity  the  diet  of  different  infants  necessary  to 
normal  weight  increases  must  vary  within  very  consider- 
able limits,  the  scale  offers  information  which  is  of  in- 
estimable value. 

The  following  may  be  taken  as  working  averages  for 
comparative  purposes,  and  the  estimation  of  over-  and 
under-  weight  in  infants  coming  under  observation. 

Average  weight  at  birth  7  pounds  (3200  Gm.) 

Average  initial  loss  10  ounces  (300  Gm.)  or  about  one-tenth 

of  the  body  weight  at  birth. 
Birth  "weight  regained  usually  by  the  fourteenth  day. 


122  INFANT    FEEDING. 

Weight  is  doubled  at  the  end  of  the  fifth  month. 

Trebled  at  the  end  of  the  first  year. 

Average  weekly  gain  during  the  first  five  months  should 

approximate  5  ounces   (150  Gm.),  during  the  remainder 

of  first  year  4  ounces  (120  Gm.). 

Yearly  gain  during  the  second  year  6  pounds  (2727  Gm.). 
Gain  during  the  third  year  4.5  pounds  (2000  Gm.). 
Gain  from  the  fourth  to  the  eighth  year,  4  pounds  annually 

(1800  Gm.). 
Gain  from  the  eighth  to  the  eleventh  year,  6  pounds  annually 

(2700  Gm.). 

An  accurate  scale  is  a  necessary  equipment  for  proper 
infant  feeding.  Parents  should  be  encouraged  to  pur- 
chase a  balance  scale  with  a  large  scoop. 

However,  it  is  not  sufficient  to  base  the  determination 
of  the  amount  of  food  on  the  weight  of  the  baby  alone, 
since  two  infants  of  the  same  weight  may  have  decidedly 
different  nutritional  requirements,  dependent  upon  vari- 
ous factors.  The  fat  baby  requires  less  food  per  pound 
than  the  thin  baby — the  overfed  less  than  the  underfed 
infant ;  and  the  sick  baby  must  of  necessity  be  fed  within 
its  limits  of  tolerance  during  the  acute  part  of  its  illness, 
and  the  body  losses  must  be  compensated  by  increases  in 
the  diet  beyond  those  which  we  have  learned  to  consider 
as  the  normal  feedings  per  pound  body  weight,  as  its 
tolerance  for  food  permits  during  convalescence. 

A  healthy  infant  should,  therefore,  show  a  regular  gain 
within  certain  limitations.  It  is  not  absolutely  necessary 
for  an  infant  to  add  to  its  body  weight  every  day,  as  daily 
irregularities  are  rather  the  rule  than  the  exception.  The 
relation  of  the  time  of  weighing  to  the  feeding,  defeca- 
tion, and  urination  are  factors  which  must  always  be 
taken  into  consideration.  Therefore  under  normal  condi- 
tions it  is  sufficient  to  weigh  the  infant  once  a  week.  It 
is  especially  wise  to  impress  this  upon  a  nervous  mother. 

Further,  we  must  not  forget  that  the  weight  curve  of 
the  nursing  infant  and  that  of  the  artificially  fed  infant 
differ  widely,  so  that  they  cannot  be  compared  directly. 


MILK  DILUTIONS  WITH  CARBOHYDRATES.       123 

The  artificially  fed  infant,  although  in  the  beginning 
gaining  less  than  the  breast-fed  infant,  in  the  course  of  a 
year  reaches  the  same  weight  as  the  breast-fed  infant, 
who  at  first  showed  larger  gains,  but  later  lagged  some- 
what in  its  gains.  Much  more  important  than  the  weight 
itself  is  the  rising  series  of  successive  weight  figures. 

The  clinical  aspects,  that  is,  the  general  well-being  of 
the  infant  must  be  given  equal  importance  with  the  per- 
centage and  energy  value  of  the  formula.  In  a  consider- 
ation of  the  latter  two  important  factors  in  successful 
feeding,  the  chemical  composition  must  be  considered  of 
equal  importance  with  the  caloric  value.  Otherwise  one 
meets  with  profound  disturbances  due  to  feeding  of  in- 
sufficient or  excessive  amounts  of  the  components  of  the 
diet,  difficult  of  interpretation. 

It  may  therefore  be  stated  that  the  infant  must  be  fed 
amounts  of  fat,  protein,  carbohydrates,  and  salts  and 
water  suitable  to  its  constitution,  age,  and  physical  de- 
velopment, and  that  these  ingredients  should  be  in  proper 
proportion  and  of  sufficient  quantity  to  meet  the  caloric 
requirements  of  its  tissues  for  growth  and  development. 
Again,  we  must  not  overlook  the  fact  that  the  constitu- 
ents of  the  diet  must  be  in  such  form  as  to  allow  of  nor- 
mal digestion  and  assimilation. 

We  have  spoken  of  the  wide  range  of  tolerance  of  in- 
fants to  their  foods,  and  have  mentioned  that  this,  in  all 
probability,  accounts  to  a  very  great  degree  for  the  fact 
that  so  many  men  have  been  successful  in  the  feeding  of 
infants  on  a  variety  of  mixtures  which  varied  greatly 
both  quantitatively  and  qualitatively.  There  is  in  all 
probability  another  factor  which  is  important  in  explain- 
ing these  successes,  namely,  the  fact  that  to  a  certain  ex- 
tent fats,  carbohydrates,  and  proteins  are  interchange- 
able in  their  metabolic  functions. 

Proteins.  After  passing  through  the  intestinal  wall 
proteins  have  three  functions  to  perform :  ( 1 )  to  replace 
used  protein  (lost  through  urine,  sweat,  digestive  juices, 


124  INFANT   FEEDING. 

cell  destruction,  etc.)  ;  (2)  to  satisfy  cell  growth,  which 
would  be  impossible  without  proteins;  (3)  to  furnish 
fuel  for  part  of  the  dynamic  loss  (fats  and  carbohydrates 
are  the  natural  fuel,  the  protein  combustion  being 
incidental  only). 

There  is  three  times  as  much  protein  in  cow's  milk  as 
in  human  milk.  The  reason  for  this  is  obvious,  when 
we  recall  that  the  ratio  of  the  growth  of  the  calf  to  that 
of  the  infant  is  about  as  2  to  1.  Furthermore,  the  protein 
in  cow's  milk  consists  chiefly  of  casein  (3.02  per  cent.) 
and  little  lactalbumin  (0.53  per  cent.),  while  human  milk 
contains  0.59  per  cent,  of  casein  and  1.23  per  cent,  of 
lactalbumin. 

The  proteins  are  characterized  by  containing  nitrogen. 
If  the  nitrogen  is  determined  in  the  food  eaten  during  the 
period  of  the  experiment,  it  is  evident  that  a  balance  may 
be  struck  which  will  determine  whether  the  body  is  re- 
ceiving in  the  food  as  much  protein  nitrogen  as  it  is 
metabolizing  and  eliminating  in  the  excreta.  If  there  is 
a  plus  balance  in  favor  of  the  food,  it  is  evident  that  the 
body  is  laying  on  or  storing  protein,  while  if  the  balance 
is  minus,  the  body  must  be  losing  protein.  During  the 
period  of  growth,  in  convalescence,  etc.,  the  body  does 
store  protein,  and  under  these  conditions  the  balance  is  in 
favor  of  the  food  nitrogen. 

It  is  important  also  to  bear  in  mind  that  nitrogen  or 
protein  equilibrium  may  be  established  at  different  levels 
in  order  to  explain  the  good  feeding  results  with  what 
may  be  an  excessive  protein  diet.  That  is,  an  infant  who 
has  been  receiving  1.5  Gm.  of  protein  per  Kg.,  and  who 
has  excreted  the  greater  part  thereof,  retaining  only  such 
portion  as  is  needed  for  the  body  growth,  will,  upon 
being  fed  larger  quantities,  retain  only  a  similar  amount 
for  body  growth,  excreting  the  difference  in  the  urine, 
sweat,  and  feces.  The  true  cell  life  does  not  depend  on 
what  has  been  ingested,  absorbed  and  temporarily  fixated, 
to  be  eliminated  soon  afterwards,  but  on  the  constant  and 


MILK  DILUTIONS  WITH  CARBOHYDRATES.       125 

stable  fixation.  The  body  may  become  adapted  to  over- 
feeding and  overfixation,  but  this  is  usually  of  only  a 
short  duration,  and  the  excretion  of  the  oversupply  is 
never  long  delayed.  Experimentally,  it  is  found  that 
there  is  a  certain  low  limit  of  protein  which  just  suffices 
to  maintain  nitrogen  equilibrium.  Rubner  found  that 
when  5  per  cent,  of  the  total  energy  intake,  was  in  protein 
that  it  was  sufficient  for  maintenance,  and  that  even  4 
per  cent,  was  sufficient  to  supply  its  actual  need  when 
amply  supplied  with  carbohydrate.  However,  7  per  cent. 
was  necessary  to  keep  up  the  normal  growth. 

Examination  of  the  dietaries  of  civilized  races  shows 
that,  on  the  average,  100  to  120  Gm.  of  protein  are  used 
daily  by  an  adult  man.  A  variable  portion  of  this  amount 
passes  into  feces  in  undigested  form,  but  we  may  assume 
that  about  100  to  105  Gm.  are  absorbed,  and  actually 
metabolized  in  the  body.  If  we  take  into  account  the 
weight  of  the  body,  this  amount  of  protein  may  be  esti- 
mated as  equivalent  in  round  number  to  1.5  Gm.  of  pro- 
tein, or  0.23  Gm.  nitrogen,  per  kilogram  of  body  weight. 
Chittenden  believes  that  the  daily  quota  of  protein  per 
kilogram  of  body  weight  may  be  reduced  to  one-half  this 
quantity,  from  1.5  Gm.  to  0.75  Gm.  of  protein,  or  0.12 
Gm.  of  nitrogen,  per  kilogram  body  weight. 

If  the  body  can  be  kept  in  good  condition  upon  0.75 
Gm.  per  kilogram  per  day,  will  an  ingestion  of  more  than 
this  (say  twice  as  much)  prove  injurious  or  beneficial  or 
indifferent  to  the  body?  The  full  and  satisfactory 
answer  to  this  question  must  be  deferred  until  more  ex- 
perience is  obtained.  The  newer  conceptions  in  regard 
to  the  digestion  and  nutritive  history  of  the  protein  foods 
seem  to  favor  the  adoption  of  a  low  protein  diet. 
Mankind,  when  left  to  the  guidance  of  the  natural  appe- 
tites, has  always,  when  possible,  adopted  the  high  pro- 
tein level  of  90  to  100  Gm.  per  day.  That  mankind  has 
made  a  mistake  in  adopting  the  higher  protein  level  can 
hardly  be  claimed  on  the  basis  of  our  present  knowledge. 


126  INFANT  FEEDING. 

The  chief  demands  for  protein  are  to  compensate  for 
wear  and  tear,  and  to  provide  for  growth. 

Sugars  and  starches,  when  added  to  a  diet  sufficient  to 

/  meet  an  infant's  needs,  will,  temporarily  at  least,  cause 

'  a  greater  nitrogen  retention.    Fats  have  little  or  no  such 

'  Influence.    Nitrogen  to  be  retained  must  be  built  up  into 

living  protoplasm,  and  to  accomplish  this  salts  must  be 

available.    Unless  they  are  present,  the  nitrogen  is  again 

excreted.     Approximately  1.7  Gm.  of  ash  are  retained 

for  each  1  Gm.  of  nitrogen  (Howland),  or  0.3  Gm.  of 

ash  for  each  1  Gm.  of  protein. 

Hoobler  believes  that  the  protein  needs  of  the  infant 
are  supplied  when  7  per  cent,  of  its  caloric  needs  is  fur- 
nished in  protein  calories,  and  states  that  three-fourths  of 
an  ounce  of  whole  or  skim  milk,  or  1.3  Gm.  of  protein 
per  kilogram  (0.6  Gm.  per  pound)  body  weight  is 
sufficient  to  meet  these  needs.  To  make  up  the  deficiency 
in  the  caloric  needs,  he  adds  for  each  ounce  of  whole 
milk  one-third  of  an  ounce  of  sugar  or  cereal. 

Rubner  was  able  to  promote  normal  growth  when  0.7 
per  cent,  of  the  total  energy  intake  was  in  proteins. 

Cowie  finds  the  protein  requirement  in  a  two-  to 
twelve-months  infant  to  average  2.4  Gm.  per  kilogram 
(1.1  Gm.  per  pound). 

Dunn  states  that  1.0  Gm.  to  1.5  Gm.  of  protein  daily 
per  kilogram  (.4S-.7  Gm.  per  pound)  of  body  weight  is 
necessary  for  the  normal  infant. 

Camerer  states  the  following  requirements  for  each 
kilogram  of  body  weight  in  a  child  between  2  and  4 
years  of  age:  proteins,  3.6  Gm. ;  fat,  3.1  Gm. ;  carbohy- 
drates, 9.2  Gm. ;  and  water,  75.3  Gm. 

It  has  been  our  custom  to  feed  approximately  1.5 
ounces  of  milk  to  a  pound  of  body  weight  to  the  healthy 
normal  infant,  which  would  represent  7.5  Gm.  of  protein 
per  pound  of  body  weight.  (3.3  Gm.  per  kilogram.) 

Notwithstanding  what  has  been  said  on  theoretical  and 
experimental  studies  of  the  protein  needs  of  the  arti- 


MILK  DILUTIONS  WITH  CARBOHYDRATES.       127 

ficially  fed  infant  as  compared  with  the  amount  of  pro- 
tein as  received  by  the  breast-fed  infant,  it  must  be 
granted  that  casein,  the  chief  protein  of  cow's  milk,  as 
given  in  ordinary  dilutions  to  the  infants  is  sufficient  to 
cover  entirely  the  protein  needs  of  the  infant,  and  that 
its  excess  rarely  causes  nutritional  disturbances  when 
the  tendency  to  large  curd  formation  is  prevented  by 
boiling  or  alkalinizing  the  milk. 

We  have  therefore  continued  to  use  the  protein  as 
contained  in  1.5  ounces  of  milk  per  each  pound  of  body 
weight  of  the  normal  infant,  and  in  the  underfed  we 
have  not  hesitated  to  increase  this  quantity  to  an  amount 
equal  to  2  or  even  2.5  ounces  per  pound,  thereby  approxi- 
mating 1.5  ounces  per  pound  of  what  the  baby  should 
weigh  for  its  age.  Increases  of  milk  in  the  diet  must  be 
gradual,  the  additions  being  guided  by  the  child's  ability 
to  handle  the  food.  From  what  has  been  stated,  it  may 
be  inferred  that  it  is  wise  to  establish  the  protein  content 
in  a  diet  which  may  then  be  supplemented  by  fats,  carbo- 
hydrates, and  salts,  because  protein  is  the  tissue  builder 
and  must  necessarily  be  a  basic  constituent  of  all  diets. 

Fats.  Fats  are  necessary  to  normal  growth  and 
nutrition  of  the  human  body.  But  they  to  a  greater  ex- 
tent than  the  other  food  elements  can  be  replaced  by 
proteins  and  sugars,  more  especially  the  latter.  This  ex- 
plains the  fact  that  infants  fed  on  low  fat  mixtures,  more 
]  especially  proprietary  foods,  such  as  condensed  milk,  will 
^  continue  to  gain  in  weight.  However,  such  development 
cannot  be  considered  as  normal. 

Fats  furnish  part  of  the  heat  energy  necessary  to  main- 
tain the  body  temperature.  They  are  stored  as  a  reserve 
food.  The  fat  is  a  protein  saver,  and  when  supplied  in 
proper  amount  but  little  protein  is  used  for  the  produc- 
tion of  animal  heat,  thereby  allowing  for  greater  protein 
retention  for  the  growth  of  the  body  tissues. 

Under  normal  conditions,  the  average  infant  will  digest 
from  2  to  3.5  per  cent,  of  fats.  However,  some  infants 


128  INFANT   FEEDING. 

digest  fat  badly,  and  when  a  fat  intolerance  is  once  estab- 
lished it  is  overcome  only  with  great  difficulty.  In_sjich 
cases  it  is  necessary  to  throw  the  burden  of  furnishing 
the  extra  food  necessary  on  the  carbohydrates ;  and  car-  i 
bohydrates  in  large  quantities  are  unsafe  food  for  thef 
infant.  Such  a  catastrophe  should  be  avoided,  as  infants 
receiving  an  insufficient  amount  of  fat  rarely  thrive  satis- 
factorily. We  should  therefore  aim  to  stay  within  safe 
limits.  And  it  has  been  our  experience  that  most  infants 
/  will  thrive  well  on  the  amount_pJLfat  furnished  by  the 
I  use  of  1.5  to  2.0  ounces  of  whole  milk  per  pound  body 
I  weight.  When  moderate  quantities  of  fat  are  fed,  we 
avoid  the  acute  clinical  picture  of  fat  overfeeding  asso- 
ciated with  vomiting  and  diarrhea,  and  not  infrequently  a 
high  temperature,  and  occasionally  convulsions.  On  the 
other  hand,  the  moderate  quantity  of  fat  contained  in  the 
diet  necessitates  a  high  percentage  of  carbohydrate  feed- 
ing, which  in  turn  avoids  the  so-called  fat-soap  stools, 
/with  their  tendency  to  rob  the  body  of  an  excessive 
V^  amount  of  calcium  and  magnesium.  For  the  formation 
of  a  fat-soap  stool  it  is  necessary  that  we  have  an  insuffi- 
ciency of  carbohydrates  and  a  relative  excess  of  proteins, 
as  putrefaction  is  necessary  for  the  production  of  these 
stools,  while  fermentation  opposes,  their  formation.  And 
in  the  presence  of  excessive  fermentation  the  putrefac- 
tion is  limited. 

It  may  therefore  be  stated  that  while  the  tolerance  for 
fat  of  cow's  milk  varies  greatly  in  different  individuals, 
most  infants,  however,  will  digest  and  assimilate  1.5  to 
2.0  Gm.  of  fat  per  pound  body  weight  daily,  (3.3-4.4  Gm. 
per  kilogram}  which  is  the  quantity  represented  in  1.25 
to  2.00  ounces  of  average  cow's  milk.  This  quantity  will 
also  supply  the  body  needs  for  growth  and  development, 
when  associated  with  a  sufficient  carbohydrate. 

Carbohydrates.  They  are  used  chiefly  to  supply 
heat  and  energy,  to  supply  in  part  material  for  fat  foun- 
dation, thereby  replacing  in  part  the  fat  waste.  Because 


MILK  DILUTIONS  WITH  CARBOHYDRATES.        129 

of  their  high  caloric  value  they  supply  a  large  amount  of 
energy.  They  are  efficient  sparers  of  protein,  and  will 
supply  energy  in  case  of  fat  insufficiency  in  the  diet. 
I  Synthetically,  they  are  converted  into  glycogen  in  the 
|  body.  Fat  is  formed  from  sugar  by  the  subcutaneous 
cells,  which  are  especially  adapted  to  this  function. 
Sugar  is  reduced  to  CO2  and  water,  which  may  be  meas- 
ured by  the  respiratory  metabolism.  Normally,  sugar  is 
absorbed  from  the  small  intestine  in  greater  part,  and  is 
not  found  in  the  feces.  If  absorbed  in  sufficient  quantity, 
they  will  cause  a  rapid  increase  in  weight.  When  insuffi- 
cient carbohydrate  is  supplied  to  the  body,  it  is  obtained 
by  breaking  down  the  body  protein. 

In  general,  infants  have  a  very  high  carbohydrate  tol- 
erance— much  higher  than  the  adult — and  even  infants 
suffering  from  certain  forms  of  nutritional  disturbance 
may  retain  their  ability  to  metabolize  sugar,  even  though 
it  may  have  been  reduced  for  fat  and  proteins.  Some 
infants  do  not  handle  sugar  well,  and  among  these 
certain  forms  of  gastro-intestinal  disturbances,  eczema, 
etc.,  are  of  frequent  occurrence. 

During  recent  years  much  has  been  written  on  the 
superiority  of  one  form  of  carbohydrate  over  the  other. 
I  We  can  practically^  exclude  the  monosaccharides  in  the 
/  consideration  of  the  subject,  and  speak  only  of  the  di- 
sa£charides,  of  which  lactose,  saccharose  (cane-sugar), 
and  maltose  are  the  ones  used  in  infant  feeding,  of  the 
polvsaccharides,  as  represented  by  .the  cereal  flours  and 
dextrin,  and  "last,  of  the  mixture  of  disaccharides  and 
polysaccharides,  together  with  other  substances,  these 
mixtures  being  represented  by  the  various  infant  foods 
on  the  market. 

Cane  and  Milk  Sugars.  Of  recent  years  there  has 
been  a  considerable  discussion  on  the  comparative  nutri- 
tive value  of  milk-sugar  (lactose)  and  cane-sugar 
(saccharose).  In  our  own  experience  we  have  found  little 
to  recommend  one  over  the  other  in  so  far  as  their 


130  INFANT   FEEDING. 

nutritive  value  and  the  limit  of  tolerance  is  concerned, 

I  except  as  we  have  seen  a  laxative  effect  from  the  use 

I  of  lactose,  which  is  usually  not  present  with  the  same 

quantities  by  weight  of  saccharose.     This  is,  however, 

not  seen  in  all  infants.    Cane  sugar  will  answer  the  needs 

of  most  infants.     For  practical  purposes  the  following 

quantities  of  sugar  in  addition  to  that  contained  in  the 

milk  will  meet  the  carbohydrate  requirements. 

1.  Normal    full    weight    infants    one-tenth    ounce    by 
weight  of  sugar  for  each  pound  of  body  weight  (3  grams 
for  each  pound). 

One  and  one-half  ounces  of  milk  contain  2  Gm.  making 
a  total  of  5  Gm.  to  the  pound  or  1 1  to  the  kilogram.  Holt1 
and  Fales  found  that  nursing  infants  took  on  the  average 
12  Gm.  carbohydrate  per  kilogram  daily;  artificially  fed 
infants  somewhat  more  than  this.  They  suggest  that  an 
infant  of  average  activity  at  one  year  be  allowed  about 
/  12  Gm.  per  kilogram  decreasing  the  amount  to  about 
10  Gm.  at  6  years. 

Carbohydrate  needs  beyond  that  furnished  by  one  and 
one-half  ounces  of  sugar  should  be  supplied  by_  well 
cooked  cereal  waters,  because  of  the  danger  of  sugar 
indigestion.  (See  mixed  diet,  page  145.) 

The  total  carbohydrates  (sugar  contained  in  the  milk, 
sugar  added  to  the  milk,  and  cereal,  if  used),  should 
average  from  one-eighth  to  one-fifth  ounces,  (4  to  6 
grams)  per  pound  body  weight  a  day.  One  and  one- 
half  ounces  of  milk,  averaging  4.5  per  cent,  carbohydrate 
furnishes  2  grams  of  lactose. 

2.  In  underweight  infants  the  amount  of  sugar  to  be 
added  must   frequently   be   calculated   on  the   basis   of 
the   normal   average   weight  of    the   healthy    infant    of 
the  same  age.     (See  page  143.) 

Precautions  to  be  Heeded  in  the  Addition  of  Carbo- 
hydrates to  the  Infant's  Diet: 

1.  Infants  who  have  been  on  a  low  sugar  diet'sEould     .- 

A  A1  ™'  L"  E'  and  Fales'  H    L-:  Am-  J-  Dis-  of  Children;  xxiv, 
44,  1922. 


MILK  DILUTIONS  WITH  CARBOHYDRATES.       131 

be  accustomed  to  the  change  by  gradual  increase  of  the 
sugar  content  of  their  food. 

2.  In   underweight   infants   the   amount  of   sugar  to 
start  with   should  be  calculated  on  the  basis  of  their 
present  weight.     The  quantity  of   sugar  needed   for  a 
full  weight  infant  of  the  same  age  should  then  be  ap- 
proximated as  rapidly  as  the  sugar  tolerance  permits. 

3.  In  changing  from  one  kind  of  sugar  to  another,  it 
is  always  a  safe  rule  to  reduce  the  quantity  for  a  few 
days,  further  increases  being  governed  by  the  infant's 
tolerance. 

4.  It  should  be  remembered  that  in  some  infants  the 
disaccharides   when   fed   in   full   amounts   are   liable  to 
produce   digestive    disturbances.      In   these   infants   the 
sugar  in  part  at  least  must  be  replaced  by  polysaccharides 
in  the  form  of  cereal  flours  and  cereals. 

Maltose  and  Dextrin  Compounds  can  frequently  be 
added  to  the  diet  to  advantage  in  the  presence  of  sta- 
tionary weight,  because  they  can  be  added  to  the  mix- 
ture in  quantities  approximating  one-eighth  of  an  ounce 
(4  grams)  for  every  pound  normal  weight,  when  indi- 
cated. It  must,  however,  be  remembered  that  their 
action  on  the  bowels  varies  greatly  depending  upon  their 
maltose,  dextrin  and  alkali  content.  Thus  we  find  that 
those  of  the  proprietary  foods  containing  a  considerable 
percentage  of  dextrin,  in  the  absence  of  the  potassium 
salt,  are  constipating  (Mead's  dextrimaltose  No.  1  and 
No.  2),  while  those  with  a  higher  maltose  content  to- 
gether with  potassium  carbonate  (Borcherdt's  dri  malt 
soup  and  Mead's  Dextrimaltose  No.  3)  or  with  potas- 
sium bicarbonate  (Mellin's  Food  and  Horlick's  Malt 
Food)  are  laxative. 

Cereal  Flours.     They  can  be  added  to  the  diet  of 
most  infants  early  in  life  in  quantities  varying  from  0.5 
{  to  J.9  -Gm.   (%0  to  %0  ounce)   of  flour  for  each  pound 
j  of    body    weight.      Such   an   addition    to   the    food    fre- 
quently results  in  rapid  weight  increases,  and  general 


132  INFANT   FEEDING. 

improvement  of  the  infant.  In  older  infants,  cooked 
cereals  may  be  used  in  place  of  the  starch  solutions.  We 
have  reason  to  believe  from  clinical  experience  that  the 
flours  made  from  unheated  cereals  have  a  decided  advan- 
tage over  the  dextrinized  flours  on  the  market.  Whether 
this  is  due  to  vitamines  and  vegetable  proteins  contained 
in  the  former  or  to  some  other  distinctive  property  we 
are  unable  to  state.  The  cereals  also  have  a  decided 
influence  on  the  calcium  and  magnesium  balance.  The 
cereals  cause  retention  of  these  salts,  which  may  have 
a  favorable  influence  on  the  weight. 

Salts.  Salts  are  necessary  in  digestion,  and  in  every 
step  of  metabolism,  from  absorption  to  excretion  and 
secretion.  The  role  of  salts  in  both  normal  and  path- 
ological conditions  has  been  given  constantly  increasing 
importance  in  the  last  few  years. 

Human  milk  contains  0.2  Gm.  of  ash  in  100  mils,  and 
cow's  milk  0.75  Gm.  of  ash  in  100  mils.  -  The  difference 
in  percentage  in  the  human  and  in  the  cow's  milk  is 
equalized  by  the  body  using  only  what  is  necessary  for  its 
life  and  growth.  The  salts  are  absolutely  necessary  for 
the  life  of  the  organism. 

All  the  salts  except  those  of  iron  are  found  in  larger 
amountsln  whole  cow's  milk  than  in  human  milk.  In 
I  general,  cow's  milk  contains  relatively  a  very  large 
V amount  of  calcium  phosphate,  while  the  proportion  of  iron 
in  cow's  milk  as  compared  with  human  milk  is  relatively 
small.  There  is  a  great  difference  in  the  form  in  which 
phosphorus  is  present  in  human  and  in  cow's  milk.  In 
human  milk  three-quarters  of  the  phosphorus  is  in  or- 
ganic combination,  while  in  cow's  milk  only  one-quarter 
is  in  organic  combination.  The  iron  in  neither  human  \ 
milk  nor  in  cow's  milk  is  sufficient  to  meet  the  demands 
in  the  first  year  of  life;  the  infant  must  in  part  depend  / 
on  the  iron  stored  during  fetal  life. 

The  following  table  gives  the  percentages  of  different 
salts  in  100  parts  of  ash  of  human  and  cow's  milk. 


MILK  DILUTIONS  WITH  CARBOHYDRATES.       133 

CaO      MgO      P2O5      Na2O     K2O          Cl  Fe 

Human    milk  ....  23.3      3.7      16.6      8.0      28.3      16.5      .00015 » 
Cow's  milk   23.5      2.8      26.5      7.2      24.9      13.6      .000071 

Grams  of  salts  per  100  c.c.,  of  milk. 

CaO      MgO       P2O5      Na20       K2O          Cl  Fe 

Human   milk    ..  .0458    .0074    .0345    .0132    .0609    .0358    .00017 l 
Cow's  milk 172      .02        .2437    .0465    .1885     .082     .00007 2 

In  all  the  constituents  except  P2Os  and  iron,  the  per- 
centages of  the  different  salts  in  the  two  milks  are  prac- 
tically the  same.  The  higher  proportion  of  phosphorus 
in  cow's  milk  is  due  to  the  large  amount  of  the  casein. 
Though  the  proportions  of  the  different  salts  of  the 
ash  in  cow's  milk  are  so  nearly  those  of  human  milk,  the 
amount  in  cow's  milk  is  about  three  and  a  half  times 
as  great.  Unless,  therefore,  cow's  milk  has  been  diluted 
with  more  than  twice  its  volume,  the  amount  of  these 
inorganic  constituents  furnished  to  the  infant  is  equal 
to  that  which  he  receives  in  human  milk  (Holt). 
Human  milk  contains  about  twice  as  much  iron  as  cow's 
milk,  and  dilution  of  cow's  milk  results  in  a  decrease 
in  the  iron  content,  which  must  not  be  carried  too  far 
unless  supplemented  by  other  iron-containing  food. 
,  The  infant  receiving  undiluted  cow's  milk,  with  its 
greater  salt  content,  lives  on  a  higher  plane  of  mineral 
metabolism  than  does  the  one  receiving  the  breast  milk. 
He  absorbs  60  per  cent,  of  the  total  ash,  and  retains  only 
about  15  per  cent.,  while  the  breast-fed  infant  utilizes  to 
the  full  his  opportunities,  and  absorbs  80  per  cent,  of 
the  ash,  and  retains  40  to  50  per  cent.  In  the  majority 
of  infants  this  excessive  salt  intake  undoubtedly  does  no 
harm ;  the  surplus  is  not  absorbed,  or  is  merely  eliminated. 

"Sodium  and  potassium  are  usually  well  retained,  un- 
less severe  diarrhea  is  present,  or  there  is  an  excess  of 
fat  or  of  sugar  in  the  diet.  Under  such  circumstances 


1  Ho!f  -.  Amer.  Jour,  of  Dis.  of  Child.,  Vol.  x,  1915. 

2  Langstein-Meyer :  Weisbaden,    Verlag    von    J.    F.    Bergman, 
1914,  p.  22. 


134  INFANT   FEEDING. 

they  are  lost,  and  the  loss  is  badly  borne,  and  cannot  in- 
definitely be  continued.  When  all  available  alkalies  have 
been  drawn  on,  the  infant  breaks  down  his  own  tissue 
to  furnish  more  of  these  substances,  which  is  an  explana- 
tion, for  a  part  at  least,  of  the  excessive  nitrogen  excre- 
tion under  such  conditions.  When  diarrhea  ceases,  and 
the  intake  is  sufficient,  a  positive  balance  is  rapidly 
instituted. 

"The  metabolism  of  calcium  has  been  largely  studied, 
on  account  of  its  close  relationship  to  rickets  and  tetany. 
Calcium  is  so  largely  excreted  by  the  bowel  that  it  is  im- 
possible to  say  how  much  is  absorbed,  plays  part  in  the 
organism,  and  is  then  excreted  by  the  intestine  and  urine, 
either  because  it  is  in  excess,  or  because  (as  in  the  case 
of  rickets)  the  body  cannot  utilize  it.  This  is  also  true 
of  magnesium,  and  to  a  much  less  extent  of  sodium  and 
potassium"  (Rowland). 

The  salts  are  necessary  for  building  up  of  the  body  tis- 
sue, and  each  gram  of  protein  retained  and  built  into 
body  tissue  requires  approximately  on_e-third  of  a  gram 
of  ash. 

Water.  The  quantity  of  water  necessary  for  the  in- 
fant is  not  only  of  theoretical,  but  also  of  vast  practical 
importance.  There  are  many  breast-fed  infants  who  ob- 
tain a  food  which  is  very  rich  in  other  nutritive  sub- 
stances, but  contains  only  a  small  amount  of  water. 
These  infants  may  not  gain  well  in  weight  unless  water 
is  added.  And,  besides,  in  sick  infants  it  is  occasionally 
necessary  to  feed  them  (especially  in  cases  of  vomiting, 
anorexia,  infections)  with  concentrated  food,  and  in  these 
cases  the  total  water  intake  necessary  must  not  be  lost 
sight  of. 

The  lack  of  or  inadequacy  of  water  is  much  more  dan- 
gerous to  the  infant  than  a  corresponding  deficiency  in 
the  food. 

Water  to  be  Added.  The  most  important  fact  to  re- 
member is  that  young  infants  require  a  minimum  of  one- 


MILK  DILUTIONS  WITH  CARBOHYDRATES.       135 

fifth  of  their  body  weight  in  water  daily  (3^punces  per 
pound)  and  in  their  later  months  at  least  one  sixth  of 
their  body  weight  (2l/2  ounces  per  pound). 

Water  may  be  given  twice  daily  from  a  bottle  in 
quantity  sufficient  to  meet  the  infant's  requirements  by 
feeding  the  difference  between  one-fifth  of  the  body 
weight  and  the  milk  mixture.  (A  ten  pound  baby  should 
get  30  ounces  of  fluid.  If  receiving  25  ounces  of  milk 
mixture,  a  daily  total  of  5  ounces  of  water  may  be  given 
from  a  bottle  between  feedings.) 

If  the  infant  shows  a  desire  for  larger  individual  meals 
than  are  furnished  by  following  the  amounts  outlined,  the 
total  fluids  (milk  and  diluent)  can  be  figured  on  the  basis 
of  3  ounces  to  the  pound  and  the  additional  water  re- 
quired to  meet  the  total  day's  fluid  may  be  added  to  the 
mixture  in  place  of  being  given  between  meals. 

Estimation  of  the  Caloric  Contents  of  the  Food  as  a 
Check  on  Over-  and  Under-  feeding.  Calorimetric 
estimations  of  the  diet  must  be  considered  only  as  a  check 
on  under-  and  over-  feeding,  and  not  as  a  method  of 
feeding.  In  the  infant  whose  diet  usually  consists  of 
milk  or  its  constituents  and  sugar  and  cereal  flours,  this 
is  a  very  simple  matter.  It  should,  however,  be  remem- 
bered that  there  are  considerable  variations  in  the  caloric 
requirements  of  normal  babies.  The  fat  and  well-nour- 
ished infant  will  require  less  food  to  maintain  its  body 
heat  than  the  emaciated  one.  The  sick  baby  will  rarely 
be  able  to  digest  its  full  needs  as  estimated  by  its  body 
weight.  Therefore  as  in  every  other  phase  of  infant 
feeding,  the  individual  infant  must  be  given  primary 
consideration.  It  must  be  remembered  that  the  nutri- 
tion of  the  baby  depends  upon  the  quantity  of  the  food 
assimilated,  and  not  upon  the  quantity  ingested.  Less 
food  is  being  absorbed  and  utilized  in  the  infant  with  a 
deficient  power  of  digestion,  and  overfeeding  will  re- 
tard the  infant's  progress.  A  comparative  estimate  of 
the  infant's  diet,  with  a  theoretical  minimum,  is  of  special 


136  INFANT   FEEDING. 

value  in  cases  of  doubt  as  to  whether  the  retarded  prog- 
ress is  due  to  insufficient  food  or  defective  digestion  and 
assimilation. 

Under  this  system  the  physician  reckons  the  minimum 
daily  caloric  requirements,  either  from  the  present 
weight  of  the  baby  or  what  it  should  weigh  in  health, 
and  then  chooses  the  food  necessary  to  meet  this  re- 
quirement, bearing  in  mind  that  the  fat,  carbohydrate  and 
protein  contents  of  the  diet  must  not  only  meet  the 
caloric  requirements,  but  also  be  properly  proportioned, 
so  as  to  contain  the  proper  number  of  grams  of  each  of 
the  constituents  to  meet  the  infant's  needs  for  growth 
and  development. 

Heubner  and  Rubner  gave  us  the  first  definite  estimates 
as  to  the  caloric  needs.  They  found  that  the  average 
healthy  infant  after  birth  requires  on  the  average  100 
calories  per  kilogram  body  weight,  from  six  months  to 
the  end  of  the  first  year — approximately  85  calories  per 
kilogram  body  weight — and  that  70  calories  per  kilogram 
body  weight  is  the  energy  quotient  on  which  a  baby  would 
maintain  a  weight  equilibrium. 

Dunn  places  this  minimum  caloric  requirement  for 
artificially  fed  infants  as  follows: 

Birth  to  6  months  ...  120  cal.  per  Kg.  (55  cal.  per  pound) 

6  to  12  months  100    "      "       "     (45    "      "          "    ) 

12  to  24  months  90    "      "      "     (40    "      "          "   ) 

Dennett1  gives  the  following  figures: 

Fat  infants  over  4  months  of  age  . .  40  to  45  cal.  per  pound 
Average  infants  under  4  months  of 

age  and  moderately  thin  infants  of 

any  age  50   "  55     "      " 

Emaciated  infants  (varying  with  the 

degree  of  emaciation)    60    "  65     "      "        " 


1  Infant  Feeding,  J.  B.  Lippincott  Co.,  Philadelphia,  page  58. 


MILK  DILUTIONS  WITH  CARBOHYDRATES.       137 

Brady1  gives  the  following  figures  as  his  experience 
with  institutional  children:  50  to  55  calories  for  each 
pound  during  the  first  6  to  8  months  of  life. 

Our  own  experience  coincides  with  those  of  Dennett 
and  Brady  in  that  we  find  that  the  figures  of  Heubner  do 
not  meet  the  requirements  of  any  except  the  well-nour- 
ished infants.  Underfed  infants  not  suffering  from  de- 
composition (marasmus)  must  be  fed  food  of  a  higher 
caloric  value  per  pound  body  weight  than  the  normal  in- 
fants, and  while  such  infants  must  be  fed  minimal  quan- 
tities when  first  seen,  for  a  proper  gain  in  weight  their 
normal  weight  must  be  estimated  and  their  diet  gradually 
approximated  to  the  needs  of  the  weight  that  they  should 
normally  have. 

Average  infants  under 

2  months  of  age  . .  30  to  45  cal.  per  ft>  (  65  to  100  per  Kg.) 
Average  infants  over 

2  months  of  age  ..45  "  55  "  "  "  (100  "  120  "  "  ) 
Premature  and  thin 

infants  under  2 

months  of  age  50  to  65  cal.  per  ft>  (110  to  140  per  Kg.) 

Thin  infants  older 

than  2  months,  de- 
pending upon  their 

general  condition   .  55    "  70     "      "     "    (120  "   150    "      "   ) 

During  the  first  few  weeks  of  life  of  the  artificially  fed 
infant  it  is  usually  difficult  to  approximate  these  figures 
(see  page  151). 

Increases  in  quantity  of  food  should  always  be  gradual, 
especially  in  the  presence  of  malnutrition,  and  the  infant 
carefully  observed,  and  increases  made  only  as  the  toler- 
ance for  food  permits. 

Estimation  of  the  caloric  contents  of  the  food  is  not  a 
feeding  method  and  should  be  used  only  as  a  check  on 
over-  and  under-  feeding,  the  scale,  stool,  and  general 


1 J.    M.    Brady,   Institutional   Care   of   Infants,   Archives   of 
Fed.,  1917,  34,  356. 


138  INFANT   FEEDING. 

condition,  and  particularly  the  disposition  of  the  infant, 
being  the  ultimate  guide  for  dietetic  changes. 

Energy  quotient  is  the  number  of  calories  which  the 
infant  is  getting  per  pound  or  per  kilogram  of  body 
weight.  To  determine  the  energy  quotient  of  the  diet 
multiply  the  number  of  ounces  of  each  food  ingredient  of 
the  food  mixture  by  their  caloric  values,  add  the  products 
and  divide  the  sum  by  the  number  of  pounds  or  kilo- 
grams of  the  baby's  weight. 

CALORIC  VALUES  OF  1  oz.  (30  GM.)  OF  VARIOUS  FOODS. 

Calories 

Cow's  milk  21  * 

Human  milk 21 

16  per  cent,  cream 54 

Skim  milk  11 

Buttermilk   11 

Buttermilk  mixture  21 

Albumin  milk 12 

Chymogen  milk 21 

Keller's  malt  soup  25 

Cane-sugar   (by  weight)    120 

Maltose-dextrin  compounds  (average)    110 

Malt-soup  extract,  dry,  by  weight 90 

"     by  measure 132 

Flour,  by  weight  100 

Cereal  waters  (1  oz.  cereal  to  quart)   3 

PRACTICAL  APPLICATION  OF  MILK  DILUTIONS  WITH  ADDI- 
TION OF  CARBOHYDRATES   IN   INFANT   FEEDING. 

In  the  application  of  the  rules  for  the  feeding  of  normal, 
healthy  infants,  it  must  be  remembered  that  each  infant 
must  be  fed  to  meet  its  individual  requirements,  and  the 
rules  modified  so  as  to  meet  the  demands  of  the  individual 
baby.  If  milk  dilutions,  with  the  addition  of  carbohy- 
drates are  used,  the  simplest  and  most  natural  standard 
would  be  one  that  would  tell  us  how  much  milk  and  car- 


NOTE  : — 

1  gram  of  fat  =  9.3  calories. 

'    protein  =4.1         " 

1      "       "    carbohydrate  =  4.1         " 


MILK  DILUTIONS  WITH  CARBOHYDRATES.        139 

bohydrates  per  pound  or  per  kilogram  body  weight  the 
baby  should  get.  To  be  exact  we  should  express,  or  at 
least  be  aware,  of  the  number  of  grams  of.  proteins,  fats, 
carbohydrates  and  salts  that  the  infant  is  receiving  for 
each  pound  of  its  body  weight.  We  believe  that  if  statis- 
tics on  infant  feeding  were  collected  on  this  basis  rather 
than  in  percentages  of  the  ingredients  in  the  milk  mix- 
tures (the  total  mixture  being  of  such  variable  quantity) 
the  collected  data  would  be  far  more  valuable  as  a  basis 
for  future  work  in  infant  feeding. 

DATA  AS  TO  FOODS  AND  FOOD  REQUIREMENTS  USED 
AS  A  BASIS  FOR  ESTIMATING  THE  DIET  OF  INFANTS. 

Average  cow's  milk  contains  the  following  percentages : 

Fat 4.0      per  cent. 

Protein    3.5 

Carbohydrates   4.5 

CaO  0.172 

Grams  of  food  elements  needed  as  a  minimum  by  the 

average  artificially  fed  normal  infant  in  twenty-four 
hours : 

Per  Pound.  Per  Kilo. 

Fat  1.5  to  2.0  3.3  to  4.4 

Protein  1.5  3.3 

Carbohydrates 5.0  11.0 

CaO  0.08  0.17 

Water 90.0  200.0 

The  milk  or  cream  and  skim  milk  needed  to  supply  fat 
and  protein  will  average  2  grams  of  sugar  so  it  will  be 
necessary  to  add  amount  needed  in  excess  of  this  %0 
ounce  or  (3  grams)  per  pound  or  6.6  per  kilo. 

For  each  gram  of  food  elements  in  the  mixture  the  fol- 
lowing ingredients  must  be  added : 

Fat    T!O  ounce  or  6  mils  of  cream. 

%  ounce  or  25  mils  of  milk. 
Protein  1.0  ounce  or  30  mils  of  milk 

or  skim  milk. 

Carbohydrates    MJO  ounce  or  1  Gm.  of  sugar. 

CaO   18.5    ounces    or   600  mils    of 

milk  or  skim  milk. 


140  INFANT   FEEDING. 

For  each  pound  of  body  weight  the  following  will  be 
required : 

Fat  (1.5  to  2  Gm.)  %o  to  fio  ounce  or  9  to  12 

mils  of  cream. 
1J4  to  1%  ounces  or  37.5  to 
.  50  mils  of  milk. 

Protein   (1.5  Gm.)    \l/2  ounces  or  45  mils  of  milk 

or  skim  milk. 
Carbohydrates   (3  Gm.)    . .  Mx>  ounce  or  3  Gm.  of  sugar. 

CaO  (0.08  Gm.)    \l/2  oui  -es  or  45  mils  of  milk 

or  skim  milk. 

For  each  kilogram  of  body  weight  the  following  will  be 
required : 

Fat  (3.3  to  4.4  Gm.)   20  to  27  mils  of  cream. 

85  to  110  mils  of  milk  (aver- 
age 100  mils). 

Protein   (3.3  Gm.)    95  mils  (milk  or  skim  milk). 

100  mils  in  round  figures. 

Carbohydrates  (6.6  Gm.)  . .      6.6  Gm.  of  sugar. 
CaO  (0.172  Gm.)    100  mils  in  round  figures. 

No  allowance  has  been  made  for  protein  in  cream. 

Protein  figured  at  3.5  per  cent,  in  milk. 

Therefore  to  meet  protein  and  fat  requirements  in  feed- 
ing with  diluted  whole  milk,  the  average  normal  infant 
will  require  each  day  a  minimum  of  \l/2  ounces  (45  mils) 
per  pound  or  100  mils  per  kilo  of  body  weight,  exclusive 
of  the  sugar  and  starch  which  are  added  in  preparation 
of  the  mixture. 

Practical  experience  has  taught  us  that  infants  under 
five  months  of  age  will  frequently  require  amounts  ap- 
proximating 2  ounces  (60  mils)  of  cow's  milk  per  pound 
body  weight,  except  during  the  first  few  weeks  of  life, 
when  smaller  quantities  of  whole  or  skim  milk  are  indi- 
cated (see  page  151).  With  the  institution  of  a  mixed  diet, 
the  infant  thrives  with  less  milk  per  pound  body  weight. 

In  beginning  feeding  with  cow's  milk,  mixtures  must 
always  be  started  as  weak  formulae,  more  often  using 
only  1  ounce  (30  mils)  of  cow's  milk  to  a  pound  body 


MILK  DILUTIONS  WITH  CARBOHYDRATES.       141 

weight,  gradually  increasing  the  strength  to  meet  the 
infant's  needs. 

Underweight  infants  should  at  first  be  fed  according 
to  their  present  weight,  gradually  increasing  the  strength 
of  the  mixture  as  rapidly  as  consistent  with  the  baby's 
ability  to  handle  the  diet,  and  thus  approximating  the 
needs  of  a  full  weight  baby  of  the  same  age.  These 
babies  will  frequently  take  over  2  ounces  (60  mils)  of 
milk  per  pound  body  weight. 

Number  of  Feedings  in  Twenty-four  Hours.  Three- 
hour  intervals  at  the  start,  with  7  feedings  in  twenty- 
four  hours,  for  the  first  month  (6-9-12-3-6-10-2),  6  feed- 
ings during  the  second  and  the  third  month  (6-9-12-3- 
6-10),  5  feedings  by  the  fourth  to  the  fifth  months  (6-10- 
2-6-10),  according  to  the  individual  needs  of  the  child. 

Premature  and  delicate  infants  with  a  tendency  to 
vomit  are  exceptions,  and  may  be  fed  smaller  amounts  at 
more  frequent  intervals,  even  two  hours,  if  indicated. 
Catheter  feeding  may  be  necessary,  in  which  case  the 
longer  interval  will  usually  answer. 

Amounts  at  Each  Feeding.  On  3-hour  intervals  the 
quantity  should  be  one  ounce  more  than  baby  is  months 
old.  Example:  A  3-months-old  baby  takes  four  ounces 
per  feeding  if  fed  every  three  hours. 

On  four-hour  intervals,  the  quantity  is  ttvo  ounces 
more  than  the  baby  is  months  old.  Example:  A  6- 
months-old  baby  takes  eight  ounces  per  feeding  on  a  four- 
hour  schedule. 

The  increases  per  feeding  are  made  gradually  until  the 
feedings  reach  eight  ounces. 

Exceptionally,  infants  cannot  take  this  amount  at  each 
feeding,  and  when  vomiting  is  the  result  of  overfeeding, 
the  quantity  can  be  reduced  and  an  extra  meal  sub- 
stituted. Some  infants  will  demand  larger  feedings. 

After  the  fourth  month  the  average  infant  will  take 
daily  1  quart  of  the  food  mixture. 


142  INFANT   FEEDING. 

By  the  sixth  month  four  meals  of  8  ounces  each  of 
milk  mixture  may  be  given,  and  a  fifth  meal  of  broth 
and  vegetables  (sec  rules  for  mixed  diet,  page  145}. 

Water  to  be  Added.  In  our  own  experience  we  have 
found  that  a  concentrated  milk  mixture  does  not  disturb 
the  infant's  digestion  when  the  milk  is  boiled  or  alkalin- 
ized  by  sodium  citrate,  sodium  bicarbonate,  or  lime- 
water.  The  amount  of  water  is  calculated  by  multiplying 
the  number  of  feedings  by  the  amount  of  each  feeding, 
and  subtracting  the  milk  to  be  given. 

Example:  Baby  aged  3  months  should  receive  5  feed- 
ings, 5  ounces  each  (age  in  months  plus  2)  or  a  total  of 
25  ounces  for  the  day.  Subtracting  16.5  ounces  (11 
pounds  body  weight  and  1.5  ounces  of  milk  for  each 
pound) gives  us  8.5  ounces  as  amount  of  water  to  be  added. 

The  total  fluids  for  the  day  should  equal  at  least  one- 
sixth  the  body  weight.  If  the  mixture  does  not  total  this 
amount  sufficient  water  can  be  fed  between  meals. 

Carbohydrates  to  be  added.  Having  the  necessary 
amount  of  milk  and  water,  we  ascertain  the  carbohy- 
drate to  be  added. 

Cane  sugar  answers  our  requirement  for  most  cases. 

Milk  sugar  acts  as  a  laxative  in  many  infants.  Unless 
the  laxative  effect  is  desirable,  it  has  no  advantages. 

Maltose  and  dextrin  compounds  are  acceptable  to  the 
infant's  digestion  in  relatively  larger  quantities.  They 
are  not  as  sweet  as  cane  sugar.  They  are  of  practical 
value  when  large  amounts  of  cane  or  milk  are  not  well 
taken.  Because  of  their  varying  maltose,  dextrin  and 
alkali  content  some  are  constipating  and  others  are 
laxative.  This  must  be  given  due  consideration  in  their 
selection  (see  page  131,  also  see  Appendix). 

Cane  and  milk  sugar  are  added  in  such  quantities  that 
the  normal  infant  in  its  food  mixture  receives  a  total  of 
from  4  to  6  grams  of  carbohydrates  per  pound  of  body 
weight  per  day,  including  that  contained  in  the  milk  in 
the  mixture.  As  one  and  one-half  ounces  of  milk  con- 


MILK  DILUTIONS  WITH  CARBOHYDRATES.       143 

tains  approximately  2  grams  of  lactose  it  will  be  neces- 
sary to  add  from  2  to  4  grams  of  carbohydrates  for 
each  pound  of  body  weight  to  the  diet  besides  that  con- 
tained in  the  milk.  The  needs  of  the  average  normal 
infant  in  the  first  months  are  usually  satisfied  by  the 
addition  of  one-tenth  of  an  ounce  (3  grams)  of  cane 
sugar  per  pound  body  weight  to  the  milk  and  the  water 
in  the  mixture. 

When  using  maltose-dextrin  compounds  somewhat 
larger  quantities  can  often  be  fed  to  advantage.  One- 
eighth  ounce  (4  grams)  per  pound  are  usually  well  taken. 

We  do  not  hesitate  to  add  cereal  water  to  the  diet 
after  the  infant  is  one  month  old,  and  find  it  especially 
valuable  in  those  cases  in  which  we  are  feeding  cane- 
sugar,  and  in  which  the  infant  takes  a  dislike  to  its  food 
because  of  the  intense  sweetness  of  the  mixture.  One- 
sixtieth  to  one-thirtieth  of  an  ounce  (0.5  to  1.0  gram) 
of  starch  for  each  pound  of  body  weight  may  be  added 
to  the  mixture.  This  is  best  given  in  the  form  of  cereal 
waters  or  well  cooked  cereals. 

In  underweight  infants  the  amount  of  sugar  to  start 
with  should  be  calculated  on  the  basis  of  the  present 
weight,  approximating  the  quantity  needed  for  a  full 
weight  infant  as  rapidly  as  the  sugar  tolerance  permits. 

The  following  table  gives  equivalents  of  1  ounce  by 
weight  and  the  domestic  measures  of  carbohydrates  used 
in  artificial  feeding  of  infants : 


By                   By         Table-     Dessert-       Tea- 
weight          measure  spoonfuls  spoonfuls  spoonfuls 
leveled  with  a  knife. 

Cane-sugar    1  oz.  30  Cms. 

1.00  oz. 

2 

3 

6 

Milk-sugar     1     " 

1.50   " 

3 

4.5 

9 

Maltose-dextrin    .   1 

1.50   " 

3 

4.5 

9 

Flour  (wheat)    .  .   1 

2.25   " 

5 

7.5 

15 

Flour    (barley)     .   1 

1.50  " 

3 

4.5 

9 

Barley    (pearl)     .1     "     "       " 

2.50   " 

5 

8 

15 

Oats    (rolled)     ..1     "     " 

2.50   " 

5 

8 

15 

1  tablespoonful  =  1.5  dessertspoonfuls  =  3  teaspoonfuls. 


144  INFANT   FEEDING. 

To  Break  the  Curd  to  Assist  Digestion  of  Cow's 
Milk.  Many  infants  can  digest  raw  cow's  milk.  When 
not  well  taken,  the  tendency  to  formation  of  large  protein 
curds  is  relieved  by  boiling  the  milk1  from  two  to  three 
minutes  over  the  flame,  or,  better,  by  putting  in  a  double 
boiler  and  heating  until  the  water  in  the  outer  vessel 
boils  eight  minutes.  Although  the  curd  is  less  finely 
divided  by  the  use  of  the  double  boiler,  as  compared  with 
boiling  on  the  direct  flame,  it  answers  the  purpose  of 
most  infants,  and  causes  fewer  changes  in  the  milk. 

Addition  of  sodium  citrate  to  the  milk  mixtures  also 
prevents  formation  of  hard  protein  curds.  Bosworth  and 
Van  Slyke  have  shown  that  increasing  amounts  of  sodium 
citrate  added  to  the  milk  increases  the  coagulation  time 
up  to  the  point  when  1.7  grains  (0.1  Gm.)  per  ounce  (30 
mils)  is  added,  after  which  the  milk  does  not  coagulate 
at  all.  Sodium  which  is  added  replaces  some  of  the  cal- 
cium in  the  caseinate,  and  forms  calcium-sodium  case- 
inate,  and  when  rennin  -is  added  this  double  salt  is 
changed  to  calcium-sodium-paracaseinate,  which  in  the 
presence  of  sufficient  quantity  of  sodium  does  not  curdle. 
Sodium  citrate  may  be  prescribed  either  in  5-grain  tab- 
lets, adding  approximately  1  grain  for  each  ounce  of  milk 
in  the  mixture,  or  a  prescription  may  be  written  in  such 
form  that  each  teaspoonful  will  contain  sufficient  sodium 
citrate  for  the  day's  food. 

When  lime-water  is  added  to  cow's  milk  until  it  is 
neutral  or  faintly  alkaline  to  phenolphthalein,  a  basic  cal- 
cium casein  is  formed  which  is  not  acted  upon  by  rennet, 
and  will  not  form  a  curd,  even  in  the  presence  of  lime 
salts  (Van  Slyke).  Casein  is  not  coagulated  by  rennin 
when  the  solution  is  alkaline.  When  a  sufficient  amount 
of  an  alkali  is  given,  the  milk  mixture  remains  neutral 
or  alkaline  in  the  stomach,  even  after  the  stomach  has 
secreted  acid,  and  large  protein  curds  do  not  form  then. 

1  Brenneman,  J. :  Boiled  versus  Raw  Milk,  J.  A.  M.  A.,  lx,  575. 


MILK  DILUTIONS  WITH  CARBOHYDRATES.       145 

Lime-water  is  commonly  used  in  amounts  equaling  5  per 
cent,  of  the  milk  in  the  mixture  (1  ounce  to  20  ounces 
of  milk). 

Not  infrequently  we  have  found  the  adding  of  citrate 
of  soda  or  lime-water  to  boiled  milk  of  advantage  in  the 
difficult  feeding  cases,  and  in  the  presence  of  vomiting. 

Mixed  Diet  for  Young  Infants. 

As  early  as  the  second  or  third  month,  1  or  2  teaspoon- 
fuls  of  orange  juice  may  be  given  daily.  This  in  part 
at  least  counteracts  the  effect  of  boiling.  Start  with  one- 
half  teaspoonful  diluted  with  water,  twice  daily,  and 
increase  gradually  until  the  juice  of  a  whole  orange  is 
given. 

Fifth  month,  a  little  well  cooked  cereal  may  be  added 
to  one  of  the  meals  (begin  with  1  teaspoonful),  adding 
part  of  the  bottle  of  milk  to  it,  the  meal  being  finished 
by  the  remainder  of  the  bottle,  or  it  may  be  given  in 
the  bottle.  Increase  until  1  to  4  tablespoonfuls  are 
added,  once  or  twice  daily. 

At  sixth  month,  infants  readily  take  a  broth  and  vege- 
table meal  as  a  substitute  for  one  of  the  milk  feedings,  in 
the  form  of  a  vegetable  and  meat  soup.  Begin  with  1 
ounce,  and  follow  by  a  second  bottle  containing  the  milk 
mixture  with  1  ounce  less  than  full  feeding.  Gradually 
replace  an  entire  milk  feeding. 

Ninth  month,  a  vegetable  soup  or  a  clear  broth 
(chicken,  lamb,  or  veal),  and  toast  or  zwieback  crumbs, 
with  an  additional  portion  of  stewed  fruits  (apples, 
prunes)  or  a  strained  vegetable  (spinach,  carrots,  pota- 
toes, asparagus  tips,  peas,  celery,  beets,  or  turnips).  The 
broth  is  usually  given  in  the  same  quantity  as  the  bottle, 
if  given  alone,  or  somewhat  less  if  either  the  tablespoon 
of  vegetable  or  fruit  is  given  in  addition. 

Spinach,  carrots  or  other  vegetables  may  appear  in  the 
stool  apparently  unchanged,  unless  they  are  finely  pureed. 
This  may  be  disregarded  if  there  are  no  signs  of  intes- 

10 


146  INFANT   FEEDING. 

tinal  irritation  as  the  salts  and  vitamines  are  usually 
extracted,  the  colored  cellular  part  remaining.  It  is  to 
be  remembered  that  the  tubers,  such  as  potato,  are  in 
reality  largely  starch  and  although  valuable  for  their 
mineral  content,  they  do  not  replace  root  or  leaf  vege- 
tables in  the  diet. 

CALORIC  VALUES  OF  FOODS. 

Amount  Gal. 

Apple  sauce  1  ounce  30 

Bacon  (slice)   %  ounce 30 

Bread   average  slice,  33  Gm 80 

Butter 1  pat  (%  ounce)   80 

Cereal    (cooked)    1     heaping     tablespoonful 

(1  ounce)  50 

Carrots   (cooked)    1  ounce  13 

Crackers       (soda      or 

Graham)    1  ounce  100 

Cream  (16  per  cent.)  1  ounce  54 

Custard  1  ounce  60 

Egg  1   (1.5  ounces)    80 

Egg  (white)    1  30 

Egg  (yolk)    1  50 

Gelatin   1  ounce  50 

Malt  extract  1  ounce  89 

Meat   1  ounce 50  to  70 

Milk  (whole)    1  pint 350 

Milk  (whole)    1  ounce  21 

Potato   (whole)    1  medium  sized  90 

Potato   (mashed)    1  heaping  tablespoonful 70 

Rice   (boiled) 1  tablespoonful    60 

Soup    (vegetable)    1  ounce  15 

Soup   (chicken)    1  ounce  8 

Toast  average  slice  80 

Vegetables     (peas,    beans, 

carrots)    1  heaping  tablespoonful  30 

Vegetable     (cooked    spin- 
ach)  1  heaping  tablespoonful 16 

These  caloric  values  are  approximate  for  the  most  part, 
but  are  sufficiently  accurate  for  practical  purposes.  Thus 
the  caloric  value  of  a  particular  menu  is  easily  figured. 


MILK  DILUTIONS  WITH  CARBOHYDRATES.       147 

Feeding  Example  No.  1.  Normal  Infant,  Age  Three 
Months.  The  infant  should  weigh  11  pounds  (average 
birth-weight  7  pounds,  plus  4  pounds,  representing  a 
gain  of  5  ounces  weekly  for  thirteen  weeks). 

Estimating  1%  ounces  of  milk  per  pound  body  weight, 
give  16%  ounces  of  milk. 

Adding  three  grams  of  cane  sugar  per  pound  or  1 
ounce  for  each  ten  pounds,  is  1.1  ounces  of  sugar,  or  2% 
level  tablespoonfuls  per  11  pounds 

The  infant  should  be  fed  five  or  six  times  daily  and 
should  receive  at  each  feeding  5  ounces  of  mixture  (age 
.in  months,  plus  2  ounces).  To  make  the  total  daily 
quantity  25  or  30  ounces  as  desired  it  is  necessary  to  add 
8%  or  13%  ounces  of  water  to  the  quantity  of  milk  as 
given  above. 

For  practical  purposes  the  cow's  milk  may  be  consid- 
ered as  averaging: 

Proteins 3.5  per  cent. 

Fat 4.0    "      " 

Carbohydrates    4.0    "       " 

We  will  now  calculate  the  amounts  of  the  various  ele- 
ments in  the  mixture  and  the  grams  of  each  and  calories 
per  pound  body  weight  in  the  milk  mixture  as  given 
above  for  a  3  months  old  infant,  weighing  11  pounds. 

Carbo- 
Protein     Fat    hydrate    Salts  Cal. 

Milk,   16.5  ozs.=  495  mils  . .  17.3      19.8      19.8      3.46  Gm.      346 

Water,  8.5    "=255      "     " 

Sugar,    1.1     "  =  33  Gm 33.0      ....    '  132 

Total  mix- 
ture,  25  ozs.  =  750  mils  ..  17.3      19.8      52.8      3.46  Gm.      478 

For  each  pound  body  weight .     1.575     1.8        4.8      0.31    "  43 

We  thus  find  that  the  infant  fed  on  the  prescribed 
diet  receives  25  or  30  ounces  of  the  mixture  containing: 

Protein    1.575    Gm.  per  pound  body  weight 

Fat  1.8         "        "        " 

Sugar 4.8         "        "        " 


148  INFANT   FEEDING. 

The  mixture  containing  the  following  percentages  if 
made  up  for  25  ounces,  (It  will  be  noted  that  the  per- 
centages of  the  food  elements  per  ounce  of  the  mixture 
vary  directly  with  the  amount  of  water  added  and  is 
therefore  an  unreliable  basis  for  calculation.)  and  43 
calories  per  pound  of  body  weight,  all  of  which  may  be 
considered  as  a  safe  minimum. 

Protein  2.3    per  cent. 

Fat 2.64    "       " 

Sugar 7.00    " 

A  fruit  juice  should  be  included  in  the  diet  (page  145). 

//  may  be  repeated  that  the  needs  of  the  Individual 
Infant  are  to  be  covered  by  the  Diet,  and  food  of  Higher 
Caloric  Value  per  pound  body  weight  is  needed  by  some 
Infants.  (Pages  140,  141  and  150.) 

The  mixture  may  readily  be  strengthened  to  meet  indi- 
cations for  more  fat  and  protein  by  the  addition  of  milk, 
and  more  carbohydrate  by  the  addition  of  flour  and  sugar. 

Form  for  Directions  for  Preparation  and  Feeding. 

This  feeding  formula  may  be  given  to  the  mother  in 
the  following  form  with  directions  for  its  further  pre- 
paration attached. 

Name Age 

Milk  16.5    ounces 

Water 8.5    ounces 

Cane  sugar 2.25  level  tablespoon  fuls 

(Milk  Sugar :    3%  level  tablespoonfuls.) 

Place  the  above  mixture  in  a  double  boiler,  and  starting 
with  the  water  and  the  milk  mixture  cold,  allow  it  to 
remain  on  the  stove  until  the  water  in  the  outer  vessel 
boils  for  8  minutes.  A  small  double  boiler  is  preferable 
so  as  to  obtain  a  deep  column  of  milk,  thereby  holding 
the  milk  at  a  simmer. 

Feed  5  ounces  at  each  feeding,  five  feedings  at  4  hour 
intervals:  6  A.M.,  10  A.M.,  2  P.M.,  6  P.M.,  and  10  P.M. 


MILK  DILUTIONS  WITH  CARBOHYDRATES.      149 

Not  infrequently  while  the  ingredients  in  the  diet  fully 
meet  the  infant's  needs  for  growth  and  development,  the 
amount  of  the  individual  feedings  are  insufficient  to  sat- 
isfy the  appetite.  The  infant  can  usually  be  satisfied  in 
such  instances  by  adding  more  water  or  cereal  water  to 
the  mixture,  thereby  increasing  the  quantity  of  the  indi- 
vidual bottle  without  materially  altering  its  quality. 

It  should  also  be  remembered  that  some  infants  may 
require  more  milk  than  1%  ounces  per  pound  body 
weight,  or  again,  occasionally  an  infant  cannot  take  a 
formula  as  strong  as  that  given  above,  because  of  an 
inability  to  handle  one  or  more  of  the  cow's  milk  ele- 
ments, more  commonly  fat,  protein  or  the  excess  of  salts. 
In  all  exceptional  cases  the  individual  infant  must 
necessarily  have  its  needs  fulfilled,  by  an  increase  or 
decrease  in  the  milk  components. 

Feeding  Example  No.  2.  Normal  Infant,  Age  Eight 
Months.  The  infant  should  weigh  17.25  pounds  (average 
birth-weight  7  pounds),  which  should  be  doubled  in  the 
first  five  months  (14  pounds),  plus  a  gain  of  4  ounces 
a  week  for  the  remaining  thirteen  weeks  (3.25  pounds). 

The  following  mixture  will  be  prepared : 

1.5  ounces  of  milk  per  pound  body  weight,  equals  26 
ounces. 

Water  to  make  one  quart,  equals  6  ounces. 

Sugar  1.5  ounces.  As  stated  on  page  130  the  amount 
of  sugar  to  be  added  is  usually  limited  to  1.5  ounces, 
further  carbohydrate  needs  being  furnished  by  the  ad- 
dition of  cereal  waters  or  cereals. 

Starch  0.25  ounce  or  8  grams  (approximately  %0 
ounce  or  0.5  grams  per  pound). 

This  to  be  fed  in  four  feedings  of  8  ounces  each,  and 
the  fifth  may  be  replaced  by  a  soup  and  vegetable  meal. 
A  small  cereal  feeding  (2  to  4  tablespoon  fuls)  can  also  be 
given  with  1  or  2  of  the  bottles,  pouring  part  of  the 
bottle  of  milk  over  it,  and  finishing  the  meal  on  the 
remainder  of  the  bottle.  (Mixed  Diet,  page  145.) 


150  INFANT    FEEDING. 


Carbo- 

Protein 

Fat 

hydrate 

Salts 

Cal. 

Milk,     26.0  ozs 

.  =  780  mils 

..  27.3 

31.2 

31.2 

5.46  Gm. 

546 

Water,    6.0   " 

—  180   " 

" 

Sugar,     1.5   " 

=  45  Gm.  . 

45.0 

" 

180 

Starch     0.25  " 

=     8  " 

8.0 

a 

25 

Vegetable 

soup,  8.0  " 

=  240  mils  . 

.    2.0 

4.5 

8.0 

2.4    " 

144 

Cereal,  one  heaping  tablespoon- 
ful,      1.0   "    =  30 Gm 15.0      ....    "  50 

Total  feeding   29.3      35.7     107.2      7.86    "          945 

For  each  pound  body  weight  .     1.7        2.1        6.2      0.46    '  55 

Further  needs  of  the  individual  case  can  be  supplied 
by  concentrating  the  milk  until  1  quart  whole  milk  is 
given,  the  carbohydrates  in  the  mixture  being  gradually 
decreased  and  given  in  another  form,  as  gruel,  custard, 
etc. 

Feeding  Example  No.  3.  Underweight  Infant,  Age 
3  months.  Weighing  8  pounds.  To  start  with,  prepare 
the  following  mixture : 

Milk  12  ounces.  (ll/2  ounces  per  pound  present 
weight). 

Water  13  or  18  ounces.  Sufficient  to  make  5  or  6 
feedings  of  5  ounces  each. 

Cane  sugar  0.8  ounces  (1%  level  tablespoonfuls) 
(/4o  ounce  or  3  grams  for  each  pound). 

To  meet  the  requirements  of  this  infant  for  growth  and 
development,  the  needs  of  a  full  weight  infant  of  the 
same  age  must  be  approximated  as  rapidly  as  the  in- 
fant's tolerance  for  food  permits.  These  increases  can 
usually  be  made  rapidly,  if  the  infant  is  well  other  than 
for  its  underfeeding.  The  first  increases  being  made  in 
the  carbohydrates  in  the  form  of  further  addition  of 
sugar  and  cereal  waters,  until  3  grams  per  pound  of 
sugar  and  0.5  to  1.0  gram  per  pound  of  cereal  flour  in 
the  form  of  cereal  water  are  added,  calculated  on  the 
basis  of  average  full  weight,  11  pounds,  for  this  age. 


MILK  DILUTIONS  WITH  CARBOHYDRATES.       151 

The  milk  can  be  increased  until  1%  ounces  per  pound 
of  full  weight,  or  16.5  ounces  for  the  total  mixture  are 
given. 

If  the  infant  is  suffering  from  digestive  disturbances, 
it  may  be  necessary  to  start  with  1  ounce  of  milk  or 
even  less  per  pound  of  its  present  weight,  that  is  8  ounces 
or  less  in  the  mixture,  adding  only  1  or  2  grams  of 
sugar  per  pound.  It  must,  however,  be  remembered  that 
the  infant  will  require  32  calories  per  pound  body  weight 
to  sustain  it.  And  if  it  is  underfed  for  too  long  a 
period,  it  will  result  in  inanition. 

Artificial  Feeding  During  the  First  Weeks  of  Life. 
The  rules  as  given  for  infant  feeding  are  hardly  appli- 
cable for  feeding  during  the  first  one  or  two  to  three 
weeks  of  the  infant's  life.  The  infant's  first  feedings 
should  consist  of  higher  dilutions  of  either  whole  or  skim 
milk,  should  be  boiled,  and  sugar  added  in  smaller  per- 
centages than  suggested  for  the  older  infants.  Such  mix- 
tures must  of  necessity  show  a  lower  caloric  value  than 
will  meet  the  infant's  needs  for  growth  and  development, 
but,  as  suggested,  the  mixture  for  the  newborn  should  be 
composed  of  weak  formulae,  and  increased  according 
to  the  infant's  tolerance.  The  following  table  of  mixture 
will  act  as  an  outline  for  average  cases: 

DIET  FOR  NEWBORN  INFANTS  DURING  THE  FIRST  FOUR 
WEEKS  OF  LIFE. 

1st  48   3-4  5-6  7-8-9  10-11-12  13-14     3d  4th 

hours  days  days  days  days    days  week  week 

Milk  (whole),  ozs 3  4         6         8  11 

Milk  (skim),  ozs 6  8  5  4        4        2  ... 

Sugar  (cane),  dr 1       1  2  2  2         3         4  6 

Water  (boiled),  ozs.  ..   16     10  8  8  8         8        8  10 

Calories  in  mixture   ..15     81  118  148  158     215     250  321 

Feedings : 

Amount  in  ozs 1      2        2.5  2.5  2.5  3        3        3.5 

Number  daily 66        6  6  6  6        6        6 

Intervals  in  hours  ..444  4  4  444 


152  INFANT   FEEDING. 

The  mixtures  previously  mentioned  should  be  boiled  for 
three  minutes  over  the  direct  flame  or  in  a  double  boiler. 
If  the  latter  is  used,  the  water  in  the  outer  vessel  should 
be  boiling  for  eight  minutes.  Add  boiled  water  to  make 
up  the  original  quantity. 

Method  of  Feeding  a  Baby  from  the  Bottle.  Babies 
should  be  fed  while  they  are  lying  on  their  beds,  the 
upper  part  of  the  body  being  somewhat  elevated  by  means 
of  a  pillow  of  proper  thickness.  The  baby  should  be 
turned  slightly  on  the  right  side,  as  it  has  been  found  that 
the  stomach  empties  itself  sooner  in  that  position. 

The  bottle  should  always  be  held  by  the  nurse  or  at- 
tendant, until  it  is  empty.  From  fifteen  to  twenty  minutes 
should  be  occupied  with  the  meal. 

Do  the  above  rules  furnish  mixtures  of  a  quality  and 
quantity  proper  to  meet  the  infant's  needs?  If  proper 
mixtures  they  should 

(1)  Contain  approximately 

Protein    1.5  to  2.0  Gm.  for  each  pound  of  body  weight 

Fat    1.5  "  2.0     "       "       "         "        "       " 

Carbohydrates   ..  4.0  "  6.0     "       "       "         "        "       " 

(2)  Calories   per  pound  body   weight  for   normal 

infant : 

Under  2  months  of  age   30  to  45  calories 

Over  2  months  of  age  45   "   55        " 

(3)  Percentages  in  the  mixtures. 

It  is  well  to  know  the  percentages  of  the  various  ingre- 
dients in  the  diet,  as  they  will  assist  in  the  proper  inter- 
pretation as  to  the  etiology  of  food  disturbances. 

Fat.  Infants,  according  to  their  age,  under  normal 
conditions,  digest  from  2  to  3.5  per  cent,  of  fat.  Some 
infants  digest  fat  badly,  consequently  in  some  cases  it  is 
necessary  to  give  skim  milk. 

Proteins.  In  the  average  feeding  mixture  for  in- 
fants under  10  months,  2  to  3  per  cent,  of  proteins  are 
well  taken. 


MILK  DILUTIONS  WITH  CARBOHYDRATES.       153 

Carbohydrates.  They  should,  as  a  rule,  not  exceed 
6  to  7  per  cent.,  the  average  amount  in  human  milk,  in- 
cluding the  sugar  contained  in  the  milk  before  its  modi- 
fication. 

Summary. 

I.  Preparation  of  the  mixture. 

1.  Calculate  the  baby's  normal  weight. 

2.  Calculate  the  amount  of  cow's  milk  to  be  used  in  the 
preparation  of  the  mixture,  taking  1.5  ounces  of  cow's 
milk  per  pound  of  normal  body  weight  at  that  age,  which 
is  a  safe  minimum  for  a  healthy  infant. 

3.  Calculate  the  total  daily  amount  of  the  mixture  by 
multiplying  the  amount  of  each  feeding  (age  in  months 
plus  1  or  2  ounces)  by  the  number  of  feedings. 

4.  Add  water  to  make  the  mixture  up  to  this  total 
amount. 

5.  Add  3  grams  of  sugar,  and  later  0.05  to  1.0  gram  of 
starch  for  each  pound  of  body  weight. 

6.  Make  the  curd  more  digestible  by  boiling  or  alkalin- 
izing  the  mixture  or  using  cereal  water  as  a  diluent. 

II.  Checks  on  the  above  mixture. 

1.  Number  of  grams  per  pound  body  weight  of  each 
food  ingredient  in  the  mixture. 

2.  Total  caloric  value  of  mixture  and  caloric  value  per 
pound  body  weight. 

III.  Remember  that — 

1.  Orange  juice  or  codliver  oil  additions  to  the  diet 
should  be  started  by  the  second  or  the  third  month. 

2.  When  more  than  1  quart  of  milk  mixture  is  needed 
to  properly  nourish  the  infant,  most  infants  have  reached 
the  age  when  a.  mixed  diet  should  be  instituted. 

3.  These  amounts  are  relative,  and  must  be  increased 
or  decreased  according  to  the  infant's  progress  and  in- 
dividual needs,  the  above  rules  furnishing  a  safe  minimum 
for  a  healthy  infant. 


154  INFANT   FEEDING. 

4.  The  above  amounts  are  usually  insufficient  for  the 
underfed  infant  after  it  has  become  accustomed  to  the 
diet.     Frequently  it  is  necessary  to  approximate  the  re- 
quirements of  a  normal  baby  of  that  age. 

5.  Premature  and  underfed  infants  must  at  first  be  fed 
smaller  amounts. 

6.  The  food  formula  of  a  baby  clinically  healthy  and 
making  a   satisfactory  gain  in   weight  should  not   be 
changed  without  a  well-defined  indication. 

EXPLANATORY  NOTE.  For  practical  purposes  we  have  used 
pounds  for  weight,  and  ounces  for  measuring  fluids,  because  of 
the  common  use  in  the  home  of  avoirdupois  scales,  and  bottle 
and  measuring  glass  graduated  in  ounces.  We  have  also  calcu- 
lated 1  oz.  =  30  Gm.,  and  2.2  lbs.  =  l  Kg. 


CHAPTER  V. 
CREAM  AND  SKIMMED  MILK  MIXTURES. 

BY  the  use  of  16  per  cent,  cream  and  skimmed  milk  as 
the  basis  for  obtaining  various  milk  modifications,  a  wide 
range  of  combinations  of  the  various  food  elements  can 
be  obtained. 

For  feeding  purposes,  gravity  cream,  of  which  about  6 
'  ounces  or  somewhat  less  may  be  obtained  from  a  good 
quality  of  milk  contains  fat  16,  protein  3.5  and  carbohy- 
drate 4.5  per  cent.  The  skimmed  milk  may  be  obtained 
by  carefully  pouring  off  or  dipping  the  cream.  If  this  is 
carefully  performed,  it  should  contain  F  0,  P  3.5  and  C 
4.5.  Skimmed  milk  obtained  by  this  method  is  not  en- 
tirely fat  free.  However,  any  cream  remaining  in  the 
lower  portion  would  be  balanced  by  a  lesser  quantity  of 
fat  in  the  cream  used  and  the  end  result  in  making  these 
mixtures  would  be  about  the  same. 

The  average  infant  should  receive  fat  1.5  to  2  Gm.,  pro- 
tein 1.5  Gm.  and,  as  a  minimum  of  added  carbohydrate  3 
Gm.  (above  that  contained  in  the  cream  and  skimmed 
milk)  per  pound  body  weight.  These  will  be  obtained  by 
the  use  of  cream  (16  per  cent.),  skimmed  milk  and  sugar, 
which  contain  the  following: 

Cream  (16  per  cent,  fat),  in  1  ounce,  5  grams  of  fat. 
Skimmed  milk  (3.5  per  cent,  protein),  in  1  ounce,  1  gram  of 

protein. 
Sugar  (100  per  cent,  carbohydrate),  in  1  ounce,  30  grams  of 

carbohydrate. 

The  following  amounts  will  be  needed : 

For  each  gram  of  fat,  add  V:>  ounce,  or  6  mils  of  cream. 
For  each  gram  of  protein,  add  1  ounce,  or  30  mils  of  skimmed 

milk. 
For  each  gram  of  carbohydrate,  add  %Q  ounce,  or  1  gram 

sugar. 

(155)   ' 


156  INFANT   FEEDING. 

In  the  mixture  the  ingredents  will  be  used  in  the  follow- 
ing amounts  per  pound  body  weight: 

Cream,  %0  to  *io  of  an  ounce  (Fat,  1.5  to  2  grams). 
Skimmed  milk,  1#  ounce  (Protein,  1.5  grams). 
Sugar,  Ho  of  an  ounce  (Carbohydrates,  3  grams). 

In  the  mixture  the  ingredients  will  be  used  in  the  fol- 
lowing amounts  per  kilogram  body  weight: 

Cream,  27  mils  (Fat,  4.4  grams). 

Skimmed  milk,  100  mils  (Protein,  3.3  grams). 

Sugar,  6.6  grams  (Carbohydrates,  6.6  grams). 

In  the  underweight  infants  the  amounts  would  be  cal- 
culated on  the  basis  of  present  weight,  at  the  beginning, 
but  these  would  be  increased  gradually  to  the  amounts 
necessary  for  a  normal  weight  infant  of  the  same  age. 

Example:  Given  a  ten  pound  baby,  and  desiring  to 
feed  the  required  amounts  of  fat,  protein  and  carbohy- 
drates, which  may  be  taken  as  20  grams  of  fat,  15  grams 
of  protein,  and  30  grams  of  carbohydrate  for  one  day's 
food,  these  quantities  would  be  supplied  by : 

Cream 4  ounces. 

Skimmed  milk  15 

Sugar   1 

Water    8       " 

The  small  excess  of  protein  in  the  cream  may  be  con- 
sidered as  a  negligible  quantity. 

It  is  readily  seen  that  by  thinking  of  the  food  require- 
ments per  pound  or  kilogram  body  weight  of  the  infant 
that  the  danger  of  over  or  under  feeding  is  minimized  as 
compared  with  the  method  so  commonly  in  use  by  which 
the  food  ingredients  are  calculated  on  the  basis  of  the  per- 
centage content  in  the  mixture. 

There  can  be  no  doubt  as  to  the  accuracy  of  the  modi- 
fications which  can  be  obtained  by  this  method  of  feeding, 
but  as  previously  suggested,  it  has  the  disadvantage  of  re- 
quiring considerable  calculation  due  to  the  use  of  cream 
and  skim  milk  in  the  place  of  whole  milk  and  in  actual 
experience  the  disadvantages  to  healthy  infants  of  the 


CREAM  AND  SKIM  MILK.  157 

possible  excess  of  protein  in  mixtures  made  with  simple 
dilutions  of  whole  milk  have  been  exaggerated.  Prac- 
tical experience  presents  convincing  evidence  that  far 
more  infants  develop  gastro-intestinal  disturbances  from 
feeding  excessively  rich  cream  mixtures.  The  greatest 
objection  to  high  milk  feeding  is  high  protein  constipated 
stools  which  can  be  overcome  by  adding  more  sugar. 


CHAPTER  VI. 

FEEDING  IN  LATE  INFANCY  AND  EARLY 
CHILDHOOD. 

Mixed  Diet  After  the  Fourth  Month.  (See  page 
145.) 

Feeding  During  the  Last  Quarter  of  the  First  Year. 
The  following  diet  list  will  serve  as  an  example  for  feed- 
ing during  this  period : 

Nine  to  twelve  months  diet. 

6.00  A.M.  Milk  mixture,  8  ounces.  Milk,  6  ounces;  water, 
2  ounces ;  sugar,  2  level  teaspoon  fuls. 

8.30  A.M.  Orange  or  prune  juice,  J^  to  1  tablespoonful  (0.25 
to  0.5  oz.).  If  preferable,  this  may  be  given 
with  the  10  A.M.  or  2  P.M.  meal. 

10.00  A.M.  Milk  mixture,  8  ounces.  Cereal  (farina,  oatmeal, 
etc.),  2  to  4  tablespoon  fuls. 

2.00  P.M.  Vegetable  soup  or  a  clear  broth  (chicken,  lamb 
or  veal),  with  an  additional  portion  of  a 
strained  vegetable  (spinach,  carrots,  potatoes, 
etc.).  Vegetables  can  be  started  by  the  ninth 
month.  The  broth  is  usually  given  in  the  same 
quantity  as  the  bottle,  if  given  alone,  or  some- 
what less  if  a  vegetable  is  given  in  addition. 
When  starting  the  soup  feeding,  first  replace 
1  ounce  of  the  2  P.M.  bottle  by  1  ounce  of  soup 
in  another  bottle;  then  give  7  ounces  of  the 
milk  mixture.  Gradually  increase  soup  and 
diminish  milk  until  an  entire  bottle  of  milk  is 
replaced  by  soup.  Gradually  cut  water  and 
sugar  out  of  the  milk  mixture  until  full  milk 
is  given  by  the  tenth  or  eleventh  month. 

6.00  P.M.  Milk  mixture,  8  ounces,  and  bread^  zwieback 
crumbs  or  cereal. 

10.00  P.M.    Milk  mixture,  8  ounces,  if  needed. 

A  slice  of  crisp  bacon  may  be  given  to  advantage  dur- 
ing the  eleventh  and  the  twelfth  months,  probably  best 
with  the  mid-morning  meal. 

NOTE:  For  preparation  of  diets  see  Appendix. 

(158) 


FEEDING  IN  INFANCY  AND  CHILDHOOD.       159 

Four  feedings  a  day  are  usually  sufficient  during  the 
early  part  of  the  second  year.  In  such  a  diet  the  fruit 
juices  which  may  be  given  once  or  twice  a  day  should 
not  be  considered  as  meals,  and  may  be  given  between 
the  regular  feedings.  Whole  milk  is  now  fed,  and  should 
not  exceed  1  quart  daily.  The  sugar  and  water  are  de- 
creased gradually. 

Twelve  to  fourteen  months  diet. 

6.00  A.M.    Milk,  8  ounces. 

8.30  A.M.  Orange  juice,  prune  juice,  or  apple  sauce  (1  oz.) 
If  preferred,  this  may  be  given  with  the  10  A.M. 
or  2  P.M.  meal. 

10.00  A.M.    Milk,  8  ounces,  and  cereal  (farina,  oatmeal,  etc.) 
4  or  6  tablespoonfuls,  slice  of  crisp  bacon. 

2.00  P.M.    Vegetable  or  cream  soup  and  zwieback,  toast,  etc., 
or  a  clear  broth  (chicken,  lamb  or  veal),  with 
additional   portion   of  2  to  4  tablespoonfuls  of 
strained  vegetable   (spinach,  carrots,  potatoes, 
etc.).    The  broth  is  usually  given  in  the  same 
quantity  as  the  bottle,  if  given  alone,  but  some- 
what less  if  a  vegetable  is  given  in  addition.    A 
little  scraped  beef  or  beef  juice  may  occasion- 
ally be  added  to  the  vegetable.     Most  infants 
may  be  given  small  amounts  of  coddled  egg. 

6.00  P.M.  Milk,  8  ounces,  and  bread,  zwieback  or  cereal, 
custard  or  pap. 

10.00  P.M.    Milk,  8  ounces,  if  needed. 
No  milk  should  be  given  with  the  noon  meal. 
After  the  twelfth  month  cow's  milk  should  be  limited  to  from 
\l/2  to  2  pints  daily. 

Fourteen  to  eighteen  months  diet. 

6.00  A.M.    Milk  8  to  10  ounces 

8.30  A.M.  Fruit  juice  (orange  juice,  prune  juice,  or  apple 
sauce)  1  to  2  ounces. 

10.00  A.M.  Cereal,  4  to  6  tablespoonfuls,  with  2  ounces  of 
milk  or  cream,  followed  by  6  to  8  ounces  of 
milk.  Toast,  zwieback,  crackers,  or  wafers 
may  be  alternated  with  bacon. 


160  INFANT   FEEDING. 

2.00  P.M.  (1)  Vegetable  or  cream  soup  and  zwieback  or 
toast,  or  (2)  a  clear  broth  (chicken,  lamb  or 
veal),  with  an  additional  portion  of  four  table- 
spoonfuls  of  vegetable  mixture  (spinach,  car- 
rots, potatoes,  etc.).  The  broth  is  usually  given 
in  the  same  quantity  as  the  bottle,  if  given 
alone,  but  somewhat  less  if  the  vegetable  is 
given  in  addition. 

Part  or  whole  of  a  coddled  egg  with  toast, 
zwieback  or  cracker  crumbs  can  now  be  added 
to  the  above  soup  and  vegetable  meal. 

The  egg  may  be  alternated  with  beef  juice 
or  scraped  beef. 

6.00  P.M.  Cereal,  4  tablespoon fuls,  farina,  cream  of  wheat, 
oatmeal,  arrowroot,  custard  or  pap,  with  8 
ounces  of  milk.  Part  of  the  milk  may  be  given 
over  the  cereal,  or  as  bread  and  milk,  or  milk 
toast.  Jelly  or  honey  with  bread. 

10.00  P.M.  Milk,  8  to  10  ounces.  (Can  usually  be  left  out 
by  this  time.) 

Eighteen  months  to  three  years. 

7.00  A.M.  Stewed  fruit  or  orange  juice;  cereal;  crisp  bacon, 
alternate  with  soft  boiled  or  poached  egg; 
Bread  and  butter  or  toast;  milk  or  weak  cocoa. 

12 or  1  P.M.  (1)  Broth:  meat  or  vegetable  soup  thickened 
with  cereal.  (2)  Meat:  lamb  chops,  scraped 
beef,  chicken  or  beef  juice.  (3)  Vegetable: 
baked  or  mashed  potatoes;  strained  spinach, 
carrots,  turnips  or  celery.  (4)  Dessert:  gela- 
tine, custard,  cornstarch  or  rice-pudding,  or 
other  simple  dessert. 

6.00  P.M.  Cereal  and  bread  or  cracker  with  milk.  Baked 
apple,  apple  sauce  or  other  stewed  fruit. 

Other  Foods  Permitted  at  Three  Years. 

Meats.  Broiled  or  boiled  fish,  roast  or  stewed  poultry, 
raw  or  stewed  oysters,  broiled  beefsteak,  roast  or  broiled 
beef  or  mutton — all  in  moderate  quantities. 

Eggs.    Soft  boiled,  poached  or  scrambled,  1  or  2  daily. 


FEEDING   IN   INFANCY   AND   CHILDHOOD.       161 

Cereals  and  Breads.  Oatmeal,  hominy  grits,  wheaten 
grits,  cornmeal,  barley,  rice,  macaroni,  etc.  Light  and  not 
too  fresh  wheat  and  graham  bread,  toast,  zwieback,  plain 
unsweetened  biscuit. 

Soups.  Plain  soup  and  broth  of  nearly  every  kind, 
preferably  vegetable  broth. 

Vegetables.  White  potatoes,-  boiled  onions,  spinach, 
carrots,  peas,  asparagus  (except  the  hard  part),  stewed 
celery,  young  beets,  arrowroot,  tapioca,  sago. 

Fruits.  Nearly  all,  if  stewed  and  sweetened.  Of  raw 
fruits,  peaches  are  the  best;  pears,  grapes  freed  from 
seeds,  oranges. 

Desserts.  Light  puddings,  as  rice  pudding  without 
raisins,  bread  pudding,  plain  custard,  pap,  wine  jelly,  ice 
cream,  junket. 

Foods  to  be  Taken  with  Considerable  Caution. 
Muffins,  hot  rolls,  sweet  potatoes,  baked  beans,  turnips, 
parsnips,  cabbage,  egg  plant,  stewed  tomatoes,  fresh  corn, 
cherries,  plums,  raw  apples,  huckleberries,  gooseberries, 
currants,  preserved  fruits. 

Foods  to  be  Avoided.  Fried  foods  of  any  kind, 
griddle  cakes,  pork,  sausage,  highly  seasoned  food,  pastry ; 
all  heavy,  doughy;  or  very  sweet  puddings ;  unripe,  sour, 
or  wilted  fruit;  bananas,  cucumbers,  nuts,  coffee,  alco- 
holic beverages. 


11 


PART  IV. 

Nutritional  Disturbances  in  Artificially 
Fed  Infants. 


CHAPTER   I. 
MINOR  DISTURBANCES. 

1.  Vomiting. 

VOMITING  is  one  of  the  most  frequent  symptoms  in 
the  nutritional  disturbances  of  infancy  and  childhood, 
and  will  be  reviewed  from  the  standpoint  of  its  asso- 
ciation with  this  class  of  diseases,  without  reference 
to  its  occurrence  in  other  systemic  diseases. 

Overfilling  of  the  stomach  is  one  of  the  most  fre- 
quent causes  of  vomiting  in  infancy.  The  young-  infant 
vomits  easily,  and  without  effort.  The  weak  sphincter 
at  the  cardia  predisposes  to  regurgitation.  Regurgi- 
tation  of  only  a  small  portion  of  the  meal  is  desig- 
nated as  "spitting."  This  latter  symptom  has  become 
less  common  since  the  introduction  of  the  longer  feed- 
ing intervals,  which  allows  the  stomach  to  empty  itself 
thoroughly  before  the  next  feeding.  Other  than  too 
frequent  feedings,  too  large  an  individual  meal,  and 
food  too  rapidly  taken,  are  the  most  common  causes 
of  vomiting.  These  conditions  are  easily  remedied. 

Not  infrequently  overfilling  of  the  stomach  is  due 
to  swallowing  of  air  during  nursing.  Some  infants  are 
especially  prone  to  swallow  large  amounts  at  each 
feeding,  and  unless  this  is  relieved,  it  will  lead  to 
vomiting.  This  condition  is  frequently  seen  in  young 
infants  who  are  left  unattended  to  feed  from  a  bottle. 
This  results  in  their  nursing  air  from  the  partially  filled 
(162) 


MINOR  DISTURBANCES.  163 

nipple  as  the  bottle  becomes  empty.  It  should  be  an  in- 
variable rule  to  support  the  bottle  in  a  semi-upright  posi- 
tion for  all  infants  until  they  are  of  such  age  as  to  enable 
them  to  properly  hold  the  bottle  for  themselves.  This 
will  also  insure  their  getting  their  food  while  still  warm. 

Placing-  an  infant  in  an  upright  position,  preferably 
with  its  chest  against  the  mother's  shoulder  at  the  end 
of  the  nursing  and  avoiding  at  the  same  time  com- 
pression of  the  abdomen,  so  that  the  air  bubble  may 
rise  to  the  cardia  and  be  expelled,  offers  the  best  solu- 
tion for  temporary  relief.  Some  infants  develop  an 
extreme  habit  of  air  swallowing,  and  in  these  it  may 
become  necessary  to  put  the  infant  in  the  erect  posi- 
tion two  or  three  times  during  the  course  of  a  nursing. 

Excessive  handling  and  abdominal  bands  that  are 
too  tight  are  frequently  causes  of  vomiting. 

Improper  Diet.  Excessive  feeding  with  fat,  such  as 
is  frequently  seen  in  formulae  made  from  cream  mixtures 
and  top  milk  mixtures,  are  common  causes  of  vomit- 
ing, and  should  lead  to  reduction  of  the  fat  contents  in 
part  by  whole  or  skim  milk.  Excessive  quantities  of 
sugar  in  the  diet  may  also  cause  vomiting.  Vomiting 
due  to  the  large  tough  protein  curd  of  raw  milk  can  be 
obviated  by  boiling  or  alkalinizing  the  milk. 

Nervous  vomiting  or  habit-vomiting  is  an  exceed- 
ingly intractable  and  common  form  seen  in  many  in- 
fants. In  such  cases  the  slightest  excitement  may  pro- 
duce vomitin-g;  such  as  crying,  sudden  movement  of 
the  infant  by  the  mother  or  nurse. 

Spasm  of  the  cardia  or  pylorus  are  frequent  causes 
of  vomiting  more  especially  in  early  infancy.  Spasm 
of  the  cardia  is  rarely  diagnosed  except  by  the  radio- 
graph. In  our  experience  these  cases  are  found  more 
frequently  than  formerly  supposed.  These  types  of 
vomiting  may  appear  immediately  after  birth,  but  usu- 
ally do  not  develop  for  some  days  or  even  weeks,  and 
sometimes  not  until  the  infant  is  several  months  old.  In 


164  INFANT  FEEDING. 

the  milder  cases  this  may  be  the  only  symptom  and  the  in- 
fants may  obtain  sufficient  food,  and  thereby  avoid  any 
interference  with  proper  nutrition.  In  both  types  the 
vomiting  may  be  explosive.  This  is  more  common  in  the 
pyloric  type  or  when  the  two  are  associated.  The  vomitus 
shows,  as  a  rule,  little  or  no  evidence  of  disturbance  of 
digestion.  In  extreme  types  nutrition  will  suffer  and  the 
hunger  stool  is  present.  The  presence  of  increased  and 
visible  peristalsis  in  the  pyloric  type  may  lead  to  the  diag- 
nosis of  organic  stenosis.  They  can  only  be  differen- 
tiated by  the  aid  of  a  fluoroscope  and  radiograms  fol- 
lowing a  bismuth  meal,  together  with  a  careful  study 
of  the  history  of  its  development  and  the  effect  upon 
the  infant's  development. 

Congenital  hypertrophic  stenosis  of  the  pylorus  is  a 
frequent  form  of  obstruction.  Most  frequently  it 
comes  into  evidence  between  the  second  and  the  fourth 
week  after  birth.  There  is  nothing  characteristic 
about  the  vomiting  in  the  beginning.  It  soon  becomes 
forcible  and  explosive.  The  gastric  contents  may  be 
shot  out  of  the  mouth  to  a  distance  of  several  feet. 
The  vomiting  usually  occurs  soon  after  the  taking  of 
food,  but  may  occur  at  any  time,  sometimes  not  until 
just  before  the  next  feeding.  Two  or  even  more  feed- 
ings, are  sometimes  retained  and  expelled  together. 
The  vomiting  may  be  accompanied  by  pain.  Consti- 
pation quickly  develops,  because  so  little  of  the  food 
passes  through  the  pylorus  into  the  intestine,  that 
there  is  but  little  residue  to  be  passed  out  of  the  bowels. 
The  stools  are  small  and  composed  mainly  of  mucus. 
Increased  peristalsis  with  visible  waves  traveling  from 
the  left  to  the  right  and  ending  at  the  pylorus  with 
increasing  size  until  vomiting  occurs,  or  to  the  point 
of  exhaustion  on  the  part  of  the  stomach,  is  a  constant 
finding.  In  a  large  percentage  of  the  cases,  a  small 
tumor  may  be  felt  at  the  pylorus  when  the  infant  is 
quiet  and  the  abdomen  is  not  too  much  distended. 


MINOR  DISTURBANCES.  165 

Loss  of  weight  is  a  constant  symptom.  The  skin  be- 
comes dry,  the  face  pinched  and  the  baby  soon  shows 
all  the  evidences  of  starvation. 

Rumination  consists  in  repeated  regurgitations  of 
small  amounts  of  the  food  taken  and  occurs  some  time 
after  ingestion.  Some  of  this  is  promptly  swallowed 
again,  but  a  considerable  amount  may  be  lost  from 
the  mouth.  It  usually  lacks  the  forcible  character  that 
pertains  to  true  vomiting.  In  the  mild  type  the  rumi- 
nation occurs  only  at  long  intervals,  perhaps  once  or 
twice  a  day,  and  then  is  not  so  marked  as  to  be  accom- 
panied by  any  definite  loss  of  food.  This  condition 
usually  responds  readily  to  proper  hygiene  and  feeding, 
and  causes  very  little  anxiety.  In  the  severe  types  we 
find  a  nervous,  emaciated,  pale  child,  which  cries 
rather  easily  and  does  not  sleep  well.  The  food  which 
is  given  the  child  is  well  taken.  Soon  after  the  bottle 
is  taken,  the  child  begins  to  bring  the  food  up. 

The  food  which  is  brought  into  the  mouth  is  gargled 
for  a  short  time  and  then  swallowed.  This  may  hap- 
pen again  and  again,  the  interval  between  the  attacks 
becoming  exceedingly  short.  Some  of  the  infants 
stimulate  the  attacks  mechanically  by  putting  the 
hands  into  the  mouth,  others  by  rotating  or  protruding 
the  lower  jaw.  Commonly  the  regurgitation  is  initiated 
by  a  rigid  extension  of  the  body,  a  throwing  back  of 
the  head,  arching  of  the  chest  and  contraction  of  the 
abdomen.  Usually  following  the  regurgitation  the  in- 
fant makes  chewing  movements  upon  such  food  as  is 
not  expelled  and  it  is  again  swallowed.  I  have  recently 
had  such  a  case  under  observation,  which  showed  a 
(marked  dilatation  of  the  esophagus  and  cardio-  and  pylo- 
rospasm. 

Acute  gastric  indigestion  may  also  be  caused  by  the 
ingestion  of  foods  to  which  the  infant  is  not  accus- 
tomed, or  by  the  accidental  swallowing  of  foreign 
bodies. 


166  INFANT   FEEDING. 

Rarer  types  of  obstruction  of  the  gastro-intestinal 
tract  are  occasionally  seen,  such  as  congenital  or  in- 
flammatory obstruction  due  to  fibrous  bands.  Of  the 
former  I  have  recently  seen  two  cases  in  which  the 
lower  end  of  the  esophagus  was  obstructed  by  a  band 
of  adhesions,  which  was  relieved  by  operation.  Con- 
genital atresia  of  the  small  intestine  may  be  mistaken 
for  pyloric  spasm  or  stenosis.  Intussusception,  vol- 
vulus, appendicitis,  diverticulitis  and  the  different  types 
of  peritonitis  are  all  accompanied  by  vomiting.  In  all 
cases  of  vomiting  of  sudden  onset  of  unknown  cause, 
examination  should  be  made  for  incarcerated  umbilical 
and  inguinal  hernias. 

Treatment.  The  treatment  of  vomiting  varies  with 
its  cause. 

Spasm  of  the  cardia  or  pylorus  in  the  artificially  'fed 
is  often  cured  by  a  change  to  human  milk.  When 
human  milk  is  not  available,  feeding  with  a  concen- 
trated diet  as  thick  cereal  paste,1  will  frequently  relieve 
the  condition.  Small  feedings  at  more  frequent  inter- 
vals are  often  better  retained.  Re-feeding  after  vomit- 
ing may  be  necessary  to  avoid  starvation.  Boiling  and 
alkalinizing  the  milk  mixture  is  to  be  recommended. 
In  the  absence  of  organic  obstruction,  medication  with 
atropine  sulphate,  paregoric  and  calcium  salts  may  re- 
lieve the  tendency  to  spasm.  In  the  severer  cases 
daily  or  even  more  frequent  lavage  with  a  weak  solu- 
tion of  bicarbonate  of  soda  is  valuable.  It  has  been  our 
experience  that  in  some  of  the  cases  feeding  by  gavage 
resulted  in  the  disappearance  of  the  tendency  to  spasm 
in  both  the  cardia  and  pylorus  type.  In  some  of  our 
cases  rectal  instillation  of  normal  saline  or  Ringer's 
solution  at  regular  intervals  for  the  relief  of  the  anhy- 
dremia  has  seemingly  resulted  in  a  lessening  of  the 
spasm  probably  through  reflex  action. 

Congenital  Hypcrtrophic  Stenosis.  The  first  indication 
for  treatment  is  feeding  small  quantities  of  human  milk 

1  Thick  cereal  gruel — see  Appendix. 


MINOR  DISTURBANCES.  167 

at  short  intervals.  The  further  dietetic  and  additional 
treatment  is  the  same  as  that  recommended  for  pylo- 
rospasm.  Surgical  treatment,  when  indicated,  should 
not  be  too  long  delayed,  because  of  the  danger  of  too 
prolonged  starvation.  The  Rammstedt  or  its  modifica- 
tion is  the  operation  of  choice. 

Rumination.  The  feeding  of  concentrated  diets  as 
thick  cereal  paste  which  increase  the  difficulty  of  re- 
gurgitation  may  alone  result  in  a  cure.  In  other  cases 
mechanical  methods  may  be  employed  such  as  splint- 
ing and  pinning  the  arms  down  so  that  they  may  not 
reach  the  throat.  The  use  of  a  dove-tail  bandage  about 
the  chin  and  fastening  over  the  head,  or  a  cap  made 
with  tapes  which  fasten  under  the  chin,  as  suggested 
by  Batchelor1  or  plugging  of  the  nostrils,  all  have  been 
used  with  success,  but  will  be  attended  with  a  certain 
number  of  failures.  Radiographic  study  should  be 
made  of  the  esophagus,  cardia  and  pylorus  in  every 
case,  and  treatment  directed  toward  the  relief  of  any 
anatomical  anomalies  which  may  be  present.  In  older 
infants  the  psychic  condition  must  be  considered  and 
all  irritation  and  excitement  avoided.  In  the  hospital 
such  an  infant  should  be  placed  in  a  room  by  itself  or 
screened  from  its  immediate  surroundings. 

2.  Colic  and  Flatulence. 

Infantile  colic  is  due  to  distention  and  increased 
peristalsis  either  in  the  stomach  or  intestine,  or  both, 
resulting  in  spasmodic  contractions. 

The  colic  period  of  infancy  is  chiefly  the  first  three 
months.  After  this  time  the  peculiar  susceptibility 
gradually  diminishes.  The  so-called  "idiopathic"  form 
of  colic  is  more  commonly  intestinal  but  not  infre- 
quently the  stomach  alone  may  be  the  seat  of  origin. 


1  Batchelor,  M.  D.  and  R.  P. :  Am.  J.  Dis.  of  Children.    Vol.  17, 
1919.  43. 


168  INFANT    FEEDING. 

The  constant  solicitude  of  the  nurses,  because  the 
baby  has  "gas  on  the  stomach"  is  unwarranted.  All 
bottle-fed  babies  have  gas  in  the  stomach.  They 
swallow  it  with  their  meals  in  the  form  of  air.  If  the 
baby  is  gently  raised  to  a  sitting  posture  the  gas  will 
usually. "come  up."  This  may  be  done  in  the  middle 
of  a  feeding  if  the  stomach  seems  unusually  distended. 

Some  infants,  more  especially  those  of  the  neuro- 
pathic type,  seem  predisposed  to  attacks  almost  from 
birth.  They  are  the  fretful,  sleepless  type  of  infants 
and  seem  at  all  times  eager  to  take  food.  They  usually 
insist  upon  sucking  their  hands  or  some  other  object 
and  are  air  swallowers.  More  frequently  colic  is  due 
to  increased  intestinal  peristalsis,  often  secondary  to 
over-distention.  Many  cases  of  colic  appear  to  have  a 
nervous  origin  brought  about  reflexly  as,  for  example, 
through  chilling  of  the  surface  of  the  body. 

Constipation  is  very  frequently  associated  with  colic 
and  flatulence,  disappearing  with  the  institution  of  a 
proper  diet.  As  well  as  being  a  cause,  the  coexistence 
of  constipation  in  the  presence  of  other  etiological  fac- 
tors, tends  to  aggravate  the  colic.  Repeated  purgation 
for  an  existing  constipation  is  a  frequent  source  of  pain 
in  the  intestines.  More  commonly  the  habitual  colic,  as 
seen  in  the  young  infant,  may  be  taken  as  an  evidence 
of  gastric  or  intestinal  indigestion,  and  may  be  due  to 
one  of  several  causes:  (1)  Too  much  milk  at  proper 
intervals,  (2)  too  frequent  feedings,  and  (3)  mixture 
too  rich  in  fat,  or  (4)  excessive  in  carbohydrates.  Re- 
gurgitation  and  vomiting  are  commonly  associated,  and 
not  infrequently  diarrhea  results.  By  a  careful  study 
of  the  diet  and  observation  of  the  stools  the  offending 
factor  can  in  most  instances  be  eliminated.  Excessive 
flatulence  can  frequently  be  eliminated  by  reduction  or 
change  in  the  kind  of  sugar  and  cereal  gruels.  A  reduc- 
tion in  all  the  elements  of  the  food  may  be  temporarily 
necessary  in  the  presence  of  severe  symptoms. 


MINOR  DISTURBANCES.  169 

Colic  is  a  very  common  symptom  in  the  pre-menstrual 
period  of  the  mother  and  usually  is  present  until  a  free 
flow  is  established.  The  infant  should  be  left  at  the 
breast. 

Acute  attacks  of  enteritis,  peritonitis,  appendicitis,  in- 
tussusception and  volvulus  must  be  excluded  in  sudden 
acute  attacks. 

Treatment  must  be  directed  to  the  elimination  of  the 
cause. 

In  the  nervous  type  of  infants,  which  are  frequently 
termed  "colic  babies,"  this  condition  may  persist  for 
several  months  and  the  treatment  must  be  directed  to 
palliative  measures.  A  cure  will  result  only  with  im- 
proved development  and  when  the  digestive  organs  at- 
tain their  normal  functions.  This  class  of  infants  are 
easily  spoiled  and  should  be  placed  under  the  supervision 
of  a  capable  nurse,  if  the  mother  has  not  the  proper 
temperament  to  combat  the  child's  disposition. 

Not  infrequently  the  crying  due  to  underfeeding  may 
be  interpreted  as  colic.  Reduction  of  the  diet  of  these 
infants  is  a  source  of  danger.  If  the  stools  are  good, 
and  there  is  no  vomiting,  and  the  baby  is  gaining  in 
weight,  one  should  be  convinced  that  it  is  not  the  cry 
of  habit  before  making  changes  in  the  diet. 

In  breast-fed  infants  attention  to  the  health  of  the 
mother  or  wet-nurse,  avoidance  of  excitement,  regular 
exercise  and  regulation  of  the  bowels  are  necessary.  In 
both  breast-fed  and  artificially  fed  infants  prevention  of 
constipation  and  over-feeding  of  the  infant,  more  par- 
ticularly with  high  fat  and  carbohydrate  mixtures  are  to 
be  avoided. 

If  the  infant  is  doing  well,  notwithstanding  the  colic, 
it  should  not  be  removed  from  the  breast,  nor  should 
radical  changes  in  the  method  of  feeding  be  instituted 
without  definite  indications. 

In  feeding  with  raw  milk  the  stools  should  be  ex- 
amined for  protein  curds.  If  they  are  present,  the  milk 


170  INFANT    FEEDING. 

should  be  boiled  or  alkalinized.  Not  infrequently  the 
condition  will  be  relieved  in  the  artificially  fed  by  sub- 
stituting whole  or  skimmed  buttermilk  mixtures  for 
sweet  milk. 

The  addition  of  powdered  casein  in  amounts  varying 
from  5,  to  20  Gm.  dissolved  in  the  day's  milk  mixture 
will  often  relieve  colic,  in  all  probability  due  to  lessening 
of  intestinal  peristalsis.  A  similar  result  may  be  attained 
by  the  administration  of  calciurn_Jactate  two  or  three 
times  daily,  in  doses  of  0.3  to  0.6  Gm.  (5-10  Grs.). 

The  addition  of  3  to  5  mils  of  liquid  culture  of  active 
lactic  acid  bacilli  or  a  corresponding  amount  of  an  ac- 
tive culture  in  dry  form  is  valuable  in  the  treatment  of 
many  cases,  both  in  the  breast  and  artificially  fed.  It 
should  be  continued  for  some  time. 

The  administration  of  mild  carminatives  in  the  form 
of  camomile  or  fennel  tea,  peppermint  water  or  aromatic 
spirits  of  ammonia  (0.06-0.20  mil)  (1-3  minims),  or 
compound  spirits  of  ether  (0.25-0.30,  4-5  minims),  are 
often  effective  as  palliative  measures.  With  the  abdom- 
inal distention  the  most  efficient  means, of  relieving  the 
intestinal  tract  is  by  massage  or  enemata.  For  the  latter 
normal  saline,  weak  soap  suds  or  glycerine  in  water  may 
be  used.  A  glycerine  suppository  will  usually  accom- 
plish the  same  result. 

In  prolonged  attacks  dry  or  moist  heat  may  be  applied 
to  the  abdomen  together  with  a  hot-water  bag  at  the 
feet.  In  the  severe  cases  an  opiate  may  be  needed  for 
temporary  use.  Camphorated  tincture  of  opium,  in  doses 
varying  from  0.06  to  0.65  c.c.  (1-10  minims),  is  the  safest 
form  of  administration. 

3.  Constipation. 

By  this  term  is  indicated  a  condition  in  which  the 
number  of  evacuations  are  less  frequent,  smaller  in 
amount  or  firmer  and  drier  than  would  be  normal  for 


MINOR  DISTURBANCES.  171 

the  given  infant.  Constipation  must  be  regarded  as  a 
symptom.  The  term  is  a  relative  one  and  as  usually  ap- 
plied relates  more  to  the  character  than  to  the  frequency 
of  the  stool  in  the  normal  infant.  In  the  presence  of 
underfeeding  or  starvation  the  total  amount  must  be 
given  consideration  in  order  to  properly  interpret  its 
significance.  Under  normal  conditions  the  breast-fed  in- 
fant under  six  months  of  age  will  average  two  to  four 
movements  daily.  While  the  artificially  fed  infant,  ex- 
cept while  on  the  carbohydrate  rich  diet,  will  usually 
average  only  one  or  two  movements. 

In  the  Newborn.  The  complete  absence  of  stools 
due  to  congenital  malformations  of  the  gastro-intestinal 
tract,  such  as  atresia  of  the  esophagus  or  intestine,  or 
imperforate  anus,  should  not  be  classed  as  cases  of  con- 
stipation, and  the  cause  can  usually  be  ascertained  by 
careful  study  of  the  history,  time  of  onset  and  character 
of  the  accompanying  symptoms  and  a  roentgenological 
examination.  Somewhat  later  the  question  of  insufficient 
food  as  a  cause  of  minimal  stools  must  be  considered. 
This  may  be  due  to  mechanical  obstruction  due  to  spasm 
of  the  cardia  or  pylorus  or  hypertrophic  stenosis  at  these 
orifices.  The  food  taken  in  these  conditions  may  be  suf- 
ficient, but  it  is  later  lost  through  vomiting.  On  the 
other  hand,  insufficient  food  in  the  breast-fed  during  the 
first  days  or  insufficient  intake  or  improper  diet  in  the 
artificially  fed,  may  result  in  the  so-called  starvation 
stools  which  are  frequently  termed  constipation  stools, 
but  are  not  properly  so  classed.  Frequently  the  consti- 
pation is  due  to  sluggishness  of  the  intestines  because  of 
improper  stimulation  or  lack  of  response  to  the  mechani- 
cal irritation  of  the  food  due  to  muscular  weakness  or 
dilatation  of  the  intestinal  tract.  This  is  most  frequently 
seen  in  the  lower  part  of  the  large  intestine. 

In  Infancy.  During  this  age  a  large  number  of  fac- 
tors may  cause  constipation.  Not  infrequently  several 
factors  are  involved  in  a  given  case.  In  a  proper  con- 


172  INFANT   FEEDING. 

sideration  of  the  subject  it  should  be  borne  in  mind  that 
the  cause  of  the  constipation,  once  the  food  has  entered 
the  intestines  may  lie  in  any  one  of  the  segments  of  the 
tract,  and  may  be  due  to  insufficient  secretion  or  exces- 
sive absorption,  an  improper  diet  or  an  atony  of  the 
intestinal  wall. 

Mechanical.  Among'  the  more  common  types  several 
have  already  been  mentioned.  The  most  frequent  cause 
in  this  group  is  the  large  size  of  the  colon,  more  espe- 
cially the  sigmoid  flexure  and  the  rectum.  This  condi- 
tion may  be  due  to  or  result  in  an  atony  of  the  intestinal 
and  abdominal  walls,  or  may  produce  kinks  which  result 
in  temporary  obstruction  of  the  lumen.  Obstruction  may 
also  be  due  to  conditions  outside  of  the  intestine,  such 
as  fibrous  bands  or  adhesions,  which  latter  may  be  of 
pre-  or  post-natal  origin. 

Reflex  or  Spasmodic.  Reflex  or  voluntary  retention 
of  the  stools  may  be  due  to  painful  anal  conditions,  such 
as  fissures,  ulcers  or  spasm  of  sphincter.  The  latter 
condition  is  frequently  due  to  the  accumulation  of  large, 
hard,  dry  fecal  masses  in  the  lower  rectum,  the  more 
common  causes  of  which  will  be  described  under  Die- 
tetic Errors. 

Atony  of  the  Intestinal  Wall.  This  is  one  of  the 
most  important  causes  of  chronic  constipation  and  while 
not  infrequently  due  to  congenital  causes,  more  com- 
monly it  develops  after  birth.  Hyposecretion  of  the  thy- 
roid gland,  represented  in  its  extreme  form  in  cretinism, 
is  always  associated  with  constipation  due  to  atony  of 
the  entire  intestinal  tract.  A  similar  condition  is  also 
seen  in  athrepsia,  rickets  and  secondary  anemia.  All  of 
these  are  usually  associated  with  a  weakness  of  the  ab- 
dominal wall,  which  is  an  important  predisposing  cause. 
Affections  of  the  central,  peripheral  and  sympathetic 
nervous  systems  are  infrequent,  but  important  causes. 
Among  these  are  chronic  hydrocephalus,  intracranial 
hemorrhage,  inflammatory  conditions  of  the  brain  and 


MINOR  DISTURBANCES.  •       173 

spinal  cord.  Acute  and  chronic  febrile  diseases  not  in- 
volving the  gastro-intestinal  tract  are  usually  accom- 
panied by  constipation.  Improper  training  and  lack  of 
exercise  result  in  increasing  weakness  of  the  intestinal 
and  abdominal  walls.  The  same  result  may  follow  the 
excessive  use  of  cathartics  and  sedative  drugs. 

Dietetic  Errors.  Insufficient  intake  of  food  and 
water  or  an  improper  balance  of  the  diet  are  the  most 
frequent  causes  of  constipation.  Associated  with  these 
and  to  a  large  extent  dependent  upon  them  is  a  hypo- 
secretion  of  the  intestines,  liver  and  pancreas.  On  the 
other  hand,  as  will  be  described  later,  an  excessive  in- 
testinal secretion  may  result  from  improper  feeding  and 
may  in  turn  result  in  constipation,  due  to  the  formation 
of  so-called  soap  stools.  Food,  especially  its  carbo- 
hydrate contents,  is  the  normal  stimulant  of  the  intestine. 

In  the  breast-fed  infant  receiving  a  sufficient  quantity 
of  milk  we  rarely  see  true  constipation  because  of  its 
relatively  high  sugar  content.  The  condition  described 
as  constipation  in  the  breast-fed  infant  is  usually  due  to 
disproportion  between  the  peristalsis  in  the  lower  bowel 
and  over-action  on  the  part  of  the  anal  sphincter.  In 
the  underfed  breast-fed  infant,  however,  true  constipa- 
tion may  develop,  due  to  insufficient  stimulation  of  the 
intestines.  In  the  latter  class  of  cases,  however,  not 
infrequently  numerous  stools  are  passed  which  consist 
mainly  of  dark  colored  mucus.  This  represents  the  nor- 
mal secretion  of  the  colon  mixed  with  the  color  of  bili- 
ary pigments  and  a  minimum  of  food  residue.  Similar 
stools  may  be  passed  by  the  underfed  infant  on  an  arti- 
ficial diet;  this  may  be  due  to  too  small  quantities  of 
food  or  too  weak  food  mixtures,  leading  to  insufficient 
residue  to  form  a  normal  amount  of  feces.  Infants  fed 
on  cow's  milk  mixtures,  especially  when  insufficient 
sugar  is  added,  will  in  time  pass  soap  stools  which  are 
dry  and  putty-like  and  alkaline  in  reaction,  with  a  result- 
ing constipation.  This  error  in  feeding  will  be  given 


174  INFANT    FEEDING. 

further  consideration  under  the  title  of  Overfeeding 
with  cow's  milk  with  insufficient  carbohydrates.  In- 
fants fed  on  diet  low  in  fat,  although  it  may  contain 
a  sufficient  amount  of  carbohydrates  and  protein,  fre- 
quently have  an  accompanying  constipation  due  to  the 
fact  that  the  carbohydrates  and  protein  are  almost  com- 
pletely absorbed  and  little  residue  remains.  A  consider- 
able portion  of  the  fat  ingested  in  high-fat  diets  is  ex- 
creted in  the  feces  as  fatty  acids,  neutral  fat  and  fat 
soaps.  Excessive  quantities  of  slowly  fermentable  carbo- 
hydrates, such  as  starch,  will  lead  to  constipation,  unless 
accompanied  by  sufficient  sugar  which  by  its  more  rapid 
fermentation  causes  active  peristalsis.  From  the  fore- 
going a  conclusion  may  be  drawn  that  the  proper  bal- 
ancing of  a  diet,  as  discussed  under  infant  feeding,  is 
of  importance  in  the  prevention  of  constipation. 

The  boiling  of  milk  may  be  the  cause  of  constipation, 
in  large  part  due  to  the  fact  that  the  breaking  of  the 
curd  leads  to  more  rapid  digestion  and  secondly  due  to 
the  fact  that  these  smaller  curds  result  in  less  irritation 
of  the  intestinal  wall.  Both  of  these  factors  result  in 
more  complete  absorption  of  the  intestinal  content.  It 
should  be  remembered  that  the  average  infant  which  is 
thriving  on  its  diet  and  making  normal  progress,  even 
though  it  is  passing  "soap  stools,"  is  not  in  need  of 
radical  dietetic  changes.  More  commonly  a  simple  re- 
adjustment of  the  food  ingredients  will  result  in  a  change 
in  the  character  of  the  feces.  Only  a  careful  study  of 
the  physical  development  of  the  infant,  which  should 
include  examination  of  the  blood,  urine  and  osseous  sys- 
tem, should  lead  one  to  the  conclusion  that  the  constipa- 
tion is  of  pathological  significance,  due  to  an  improperly 
constituted  diet. 

Diagnosis.  Every  effort  should  be  made  to  discover 
the  cause  and  the  principal  seat  of  the  constipation.  To 
arrive  at  the  cause,  the  infant's  age  must  be  given  con- 
sideration and  a  careful  study  must  be  made  of  its  diet, 


MINOR  DISTURBANCES.  175 

habits  and  constitution.  Most  of  the  non-inflammatory 
obstructions  are  seen  in  the  first  days  of  months  of  life, 
and  are  equally  common  in  the  breast-fed.  Whether  due 
to  obstruction  or  diet,  it  is  important  to  determine 
whether  the  seat  of  the  trouble  is  in  the  small  intestine, 
colon  or  rectum.  In  both  the  breast-  and  bottle-fed  in- 
fants, if  local  means,  such  as  suppository  or  enema,  will 
result  in  rapid  passing  of  a  normal  stool,  the  fault  will 
usually  be  found  in  the  rectum,  which  is  in  need  of  in- 
creased stimulus  to  assist.it  in  emptying.  This  is  espe- 
cially common  in  breast-fed  infants,  as  well  as  artificially 
fed,  who  are  too  young  to  make  use  voluntarily  of  the 
abdominal  wall.  These  cases  are  usually  unaccompanied 
by  other  symptoms,  unless  the  stool  be  hard  and  dry, 
which  may  result  in  injury  to  the  anus.  In  the  cases  in 
which  an  improper  diet  is  the  underlying  factor,  the 
stools  are  usually  pathological  and  are  associated  with 
evidences  of  discomfort,  flatulence,  irritability  and  in- 
sufficient gain  in  weight.  Cerebral  disease,  as  well  as 
constitutional  inferiority,  as  seen  in  cretinism,  rickets, 
athrepsia  and  other  systemic  conditions  must  be  properly 
interpreted. 

Treatment.  In  breast-fed  babies,  and  not  infre- 
quently in  infants  fed  on  boiled  milk,  we  frequently  find 
a  sluggish  rectum,  which  is  evacuated  to  better  advan- 
tage by  the  use  of  simple  mechanical  means  than  by  the 
use  of  physics.  A  lubricated  catheter,  a  simple  sup- 
pository made  from  glycerine  or  soap,  or  one  or  two 
ounces  of  a  saline  enema  or  sweet  oil  injection,  can  be 
recommended.  If  properly  used,  they  are  not  harmful, 
nor  do  they  create  bad  habits  which  are  often  ascribed 
to  them.  A  regular  hour  for  their  use,  with  proper 
training,  creates  regular  habits,  and  in  most  instances 
the  condition  improves  to  such  an  extent  that  they  can 
be  discontinued.  Most  infants  can  be  trained  to  regular 
evacuations  by  the  fourth  or  fifth  month.  The  infant 
should  be  well  supported  on  the  mother's  lap,  over  a 


176  INFANT   FEEDING. 

chamber,  which  she  may  hold  between  her  knees.  This 
is  done  to  best  advantage  after  a  feeding  or  just  before 
the  morning  bath,  and  a  suppository  may  be  used  until 
the  infant  realizes  that  the  operation  is  undertaken  for 
a  purpose.  Abdominal  massage,  instituted  at  a  regular 
time,  is  of  great  assistance  in  promoting  the  emptying 
of  the  lower  bowel.  In  older  infants  this  may  be  com- 
bined with  muscle  exercises. 

The  treatment  of  the  anomalies  of  the  gastro-intestinal 
tract  causing  constipation  is  usually  surgical. 

Drugs,  except  for  temporary  use,  should  be  given  the 
last  consideration  in  the  treatment  of  constipation.  The 
stronger  cathartics,  such  as  salines,  castor  oil  or  calomel, 
are  to  be  avoided.  When  the  dietetic  and  local  measures 
fail,  the  addition  of  one  or  two  teaspoonfuls  of  milk  of 
magnesia  (Magma  magnesiae  N.  F.)  to  the  day's  feed- 
ing, or  the  administration  of  mineral  oil  in  doses  suitable 
to  the  infant's  age  may  become  necessary. 

Constitutional  conditions  must  be  corrected  by  proper 
treatment. 

Dietetic  Treatment.  In  the  breast-fed  infant  usually 
no  change  in  the  diet  is  indicated,  unless  it  is  insufficient 
in  amount.  In  the  artificially  fed  infant  a  change  in 
the  character  of  the  food  may  be  all  that  is  necessary 
to  overcome  even  protracted  constipation. 
'  In  the  presence  of  soap  stools  in  infants  who  are 
thriving,  usually  a  reduction  in  the  amount  of  whole 
milk  or  substitution  in  part  with  skimmed  milk  tempo- 
rarily and  an  increase  in  the  amount  of  sugar  will  often 
change  the  character  of  the  stool  sufficiently  to  relieve 
the  accompanying  constipation.  It  should,  however,  be 
remembered  that  the  so-called  soap  stools  are  most  fre- 
quently seen  in  the  artificially  fed  infant  on  high  milk 
mixtures,  and  that  it  is  a  common  finding  in  infants  who 
are  making  excellent  progress. 

Under  such  circumstances  radical  dietetic  changes  are 
not  indicated.  And  it  should  be  remembered  that  in  an 


MINOR  DISTURBANCES.  177 

attempt  to  overcome  this  type  of  constipation  great  in- 
jury may  be  done,  if  the  fat  and  protein  content  in  the 
diet  are  reduced  excessively.  The  use  of  local  means 
to  assist  in  emptying  of  the  rectum  is  therefore  to  be 
advised  rather  than  the  institution  of  extreme  changes 
in  the  diet. 

When  the  feeding  of  high  milk  mixtures  with  an  in- 
sufficiency of  carbohydrates  has  resulted  in  systemic 
changes  associated  with  loss  of  turgor,  stationary  weight 
and  metabolic  disturbances,  a  radical  change  in  the  diet 
is  indicated,  and  this  will  be  treated  more  in  detail  under 
the  heading,  Overfeeding  with  cow's  milk  mixtures 
with  insufficient  carbohydrates. 

In  the  presence  of  constipation,  where  the  maltose- 
dextrin  compounds  have  been  used,  a  change  to  milk- 
sugar  or  cane-sugar,  or  one  of  the  maltose-dextrin  com- 
pounds containing  a  high  percentage  of  maltose  and 
potassium  carbonate  is  often  indicated.  Occasionally 
the  addition  of  cereal  water  to  the  diet  is  of  benefit. 
Those  made  from  whole  cereal  are  more  valuable  than 
when  prepared  from  the  dextrinized  flour.  The  addi- 
tion of  from  one  to  three  tablespoonfuls  of  the  dry  or 
liquid  malt-soup  extracts  added  to  the  day's  feeding,  is 
frequently  all  that  is  necessary  to  relieve  constipation. 
In  infants  where  constipation  is  distressing  and  other 
dietetic  changes  fail,  a  week  or  two  on  Keller's  malt 
soup  will  relieve  the  condition.  (See  Appendix.) 

When  the  infant  is  old  enough  constipation  is  best 
relieved  by  the  addition  of  vegetable  soup  or  vegetable 
and  fruit  purees. 

4.  Abnormal  Stools. 

Number.  Breast-fed  infants  usually  have  one  to  four 
stools  a  day.  Bottle-fed  infants  have  one  or  two,  and 
infants  fed  on  high  milk  and  low  carbohydrate  diet  usu- 
ally require  some  local  measure  to  induce  even  one.  The 
fewer  the  stools  passed  the  greater  is  the  likelihood  that 

12 


178  INFANT   FEEDING. 

they  will  be  constipated.  Increased  peristalsis  and  secre- 
tion tend  to  increase  the  number  of  stools.  Strong  acid 
or  alkaline  bases  tend  to  irritate  the  mucous  membrane, 
more  especially  of  the  large  intestine,  with  resulting 
loose  stools.  These  types  of  stools  also  have  a  tendency 
to  irritate  the  buttocks  if  not  removed  shortly  after  be- 
ing passed.  The  hard  casein  curds,  seen  when  an  ex- 
cess of  raw  milk  is  fed,  also  tend  to  increase  peristalsis. 
Frequent  stools  are  usually  associated  with  an  increase 
in  mucus,  the  same  factors  causing  both  conditions. 

Reaction.  Tests.  Blue  and  red  litmus  paper  may  be 
used  to  test  the  reaction.  It  may  be  necessary  to  moisten 
the  stool  before  making  the  test  by  adding  a  few 
drops  of  water.  The  central  portion  of  the  stool  should 
be  used  for  making  the  test  in  order  to  avoid  its  being 
affected  by  urine.  Breast-milk  stools  are  almost  always 
acid.  Those  of  the  artificially  fed  are  acid  if  the  fat 
and  carbohydrate  in  the  diet  outweigh  the  protein.  If 
the  reverse  is  true  they  may  be  alkaline.  This  is  espe- 
cially common  with  the  skim  lactic  acid  or  sweet  milk 
mixtures  with  low  sugar  or  fat.  In  the  majority  of 
instances  stools  when  well  digested  will  be  found  to  give 
a  neutral  reaction  and  will  not  affect  the  litmus  paper. 

Color.  Breast-milk  stools  are  usually  yellow  to 
orange. 

Green  Stools.  More  especially  when  frequent  in  num- 
ber they  may  pass  with  a  greenish  tinge,  due  to  the  fact 
the  biliverdin  is  passed  before  it  can  be  reduced,  or  they 
may  be  passed  as  yellow  stools  and  turn  green  after 
passage.  Green  stools  in  an  infant  making  good  progress 
have  no  great  significance.  In  the  artificially  fed,  more 
especially,  the  soap  stools  tend  to  turn  green  upon  stand- 
ing, due  to  the  oxidation  of  the  bile  salts  from  bilirubin 
to  biliverdin.  This  is  especially  true  in  the  presence  of 
moisture,  as  from  being  saturated  with  urine. 

High  protein  stools  have  a  tendency  to  vary  from 
gray  to  olive  green  and  the  green  color  is  compatible 


MINOR  DISTURBANCES.  179 

with  normal  health  and  unless  the  infant  is  not  thriving 
should  not  lead  to  radical  change  in  the  diet. 

In  the  artificially  fed  infant  there  is  a  tendency  for 
the  stools  to  assume  a  gray,  putty-like  appearance  after 
the  first  few  weeks  on  an  artificial  diet  consisting  largely 
of  cow's  milk  and  sucrose  or  lactose.  Malt  sugars,  when 
fed  in  moderately  large  quantities,  tend  to  give  the  stools 
a  brownish  tinge. 

Gray  stools  are  those  in  which  the  bile  salts  have  been 
reduced  in  a  large  part  to  urobilin,  the  biliverdin  being 
practically  absent.  This  is  characteristic  of  the  so-called 
soap  stools  seen  in  high  milk  and  low  carbohydrate  feed- 
ing. 

Brown  stools  may  vary  from  a  light  to  a  deep  brown 
in  color.  In  most  instances  this  is  due  to  feeding  with 
the  various  maltose-dextrin  compounds.  Deep  brown 
color  is  especially  characteristic  of  feeding  with  Keller's 
malt  soup  and  when  extract  of  malt  is  added  to  the  milk 
mixtures  to  overcome  constipation.  The  color  will  vary 
directly  with  the  amount  of  malt  added.  The  cereal 
waters,  when  added  in  considerable  amount  or  strength, 
tend  to  tinge  the  stools  brown.  In  older  infants  meat, 
meat  juices,  some  of  the  vegetables,  and  iron  given  in 
the  form  of  medication  will  color  the  stools. 

Pink  Stools.  Urates  from  the  urine  may  cause  a  pink 
color  around  the  edge  of  the  feces.  This  may  also  oc- 
cur through  oxidation  of  the  bile  •  salts  or  through  the 
action  of  the  alkali  in  the  napkin  on  urine  or  stool.  The 
latter  conditions  are,  however,  exceptional. 

Dark  Stools.  Meconium  may  vary  from  green  to  dark 
brown  or  even  black.  Starvation  stools,  consisting  largely 
of  mucus  and  containing  little  fat  residue,  are  usually 
dark  brown  in  color,  due  to  the  pure  bile  salts  contained. 
The  drugs  which  are  most  frequently  administered  and 
cause  dark  stools  are  iron,  bismuth,  argyrol,  and  char- 
coal. 


180  INFANT   FEEDING. 

Bloody  Stools.  The  influence  of  blood  on  the  color 
of  the  stool  depends  upon  the  amount  and  time  of  con- 
tact with  the  intestinal  contents.  Only  blood  which  is 
passed  shortly  after  hemorrhage  retains  its  bright  red 
color.  Old  blood  gives  the  stool  a  tarry  appearance.  In 
the  new-born  it  is  often  difficult  to  differentiate  this 
from  normal  meconium.  This  should  be  borne  in  mind 
in  considering  the  possibility  of  the  presence  of  hemor- 
rhagic  disease  in  the  new-born.  In  infectious  diarrhea 
blood  is  frequently  seen  in  stools,  the  result  of  hemor- 
rhage from  ulceration  in  the  wall  of  the  colon  and  ap- 
pears as  specks  or  masses  and  is  more  often  of  bright 
red  color.  These  cases  usually  show  an  excess  of  mucus 
as  well.  Smaller  blood  masses  may  occur  in  the  pres- 
ence of  polyps  and  fissures  in  the  rectum  and  anus.  In 
intussusception  blood  and  mucus  form  the  basis  of  the 
stool  and  after  the  first  movement  there  is  little  fecal 
matter. 

Odor.  Breast-milk  stools  usually  smell  sour.  Diets 
containing  large  amounts  of  carbohydrates  in  proportion 
to  the  milk  contained  have  a  more  or  less  marked  ten- 
dency to  a  sour  odor.  This  is  especially  true  in  feeding 
with  Keller's  malt  soup.  The  soap  stool  and  the  stools 
of  infants  fed  upon  high  proteins  have  a  very  foul  odor. 
The  starvation  stool  has  a  peculiar  musty  odor,  due  to 
an  excess  of  mucus.  This  stool  is  characteristically  seen 
in  under- fed  infants  and  in  those  on  starvation  diet. 
Butyric  and  lactic  acids,  when  present  in  considerable 
amounts,  can  be  detected  by  their  odor.  The  odor  of 
decomposing  urine,  more  particularly  when  there  is  a 
marked  ammoniacal  odor,  will  cover  up  the  odor  of  the 
feces.  Therefore,  to  determine  the  fecal  odor  the  stool 
should  be  examined  shortly  after  it  is  passed. 

Characteristic  Types  of  Stools.  Starvation  stools  are 
usually  greenish  brown  or  brown  in  color,  contain  little 
fecal  matter,  are  composed  mainly  of  mucus  and  have 
a  tendency  to  have  a  moldy  or  musty  odor.  They  are 


MINOR  DISTURBANCES.  181 

most  commonly  seen  in  the  severe  types  of  "  vomiting 
and  anorexia  or  when  there  is  inability  to  swallow  the 
food,  also  at  the  end  of  the  starvation  period  in  the 
treatment  of  diarrheal  disturbances.  Care  should  be 
taken  so  that  the  starvation  stools  will  be  differentiated 
from  the  meconium  in  the  new-born,  otherwise  nursing 
on  dry  breasts  may  be  overlooked.  They  must  also  be 
differentiated  from  stools  containing  decomposed  blood. 
Curdy  Stools.  Curds  are  seen  as  undigested  masses, 
and  may  be  formed  from  fat  or  protein,  or  a  combina- 
tion of  the  two. 

Fat  curds  are  far  more  common  than  protein  curds, 
and  are  usually  seen  as  small,  soft,  whitish  or  yellow 
masses,  either  sprinkled  throughout  the  stools  or  not 
infrequently  making  up  a  large  part  of  the  stool.  They 
are  usually  intermixed  with  mucus,  which  is  present  in 
excess;  in  fact,  most  of  the  curds  are  completely  sur- 
rounded by  mucus  which  interferes  with  its  digestion. 
The  chemical  composition  can  easily  be  demonstrated 
by  the  usual  tests  for  fat.  Breast-fed  infants  very  com- 
monly show  curds  of  this  type,  and  usually  they  have 
very  little  pathological  significance  in  these  infants.  The 
mucus  is  probably  secreted  in  large  amounts  because  of 
the  irritation  caused  by  the  presence  of  fatty  acids.  Mis- 
takes are  often  made  in  the  interpretation  of  this  last 
group  of  stools.  Because  they  are  full  of  fat  curds  it 
is  supposed  there  must  be  a  fat  indigestion.  The  curds 
are  the  result  of  indigestion  or  constipation,  rather  than 
the  cause. 

Casein  curds  are  far  less  frequent,  and  present  quite 
a  different  appearance.  They  are  seen  only  in  the  pres- 
ence of  feeding  with  raw  milk.1  They  appear  as  smooth, 
hard  masses,  of  a  yellowish-brown  color,  with  white  cen- 
ter when  broken,  and  are  usually  larger  than  the  fat 
curds.  They  are  also  fewer  in  number,  and  may  be 


1  Brenneman,  J. :  Archives  of  Pediatrics,  xxxiv,  81,  1917. 


182  INFANT   FEEDING. 

found  mixed  in  feces  which  otherwise  appears  normal. 
The  addition  of  ether,  which  causes  the  fat  curds  to  go 
into  solution,  results  in  hardening  and  toughening  of  the 
protein  curds.  This  is  an  easy  method  of  differentiation. 
Such  stools  have  usually  an  offensive  odor. 

The  fat  curds,  if  numerous,  call  for  a  considerable 
reduction  in  the  fat  percentage.  The  protein  curds,  if 
numerous  and  persistent,  should  lead  one  to  reduce  the 
milk,  at  least  temporarily,  or  to  boiling  or  citrating  the 
milk,  which  causes  their  disappearance.  In  a  dyspeptic 
infant  on  a  high  sugar  diet  with  hard  curds  in  the  stools, 
reducing  the  sugar  from  the  raw  milk  mixture,  thereby 
lessening  the  frequency  of  stools  and  slowing  peristalsis, 
may  cause  the  hard  curds  to  disappear — that  is,  the  sugar 
diarrhea  which  prevented  digestion  of  the  casein  has 
been  remedied. 

Neutral  fat  is  rarely  present  in  stools,  and  when  found 
is  often  indicative  of  fat  intolerance.  In  most  instances 
when  it  is  found,  it  is  proved  later  to  be  not  from  the 
milk  but  from  castor  oil,  olive  oil,  or  some  ointment 
used  on  the  baby.  Fatty  acids  are  not  uncommonly 
found.  Breast  milk  stools  contain  them  frequently  and 
are  not  considered  pathologic.  When  found  in  cow's 
milk  stools,  it  signifies  impaired  fat  absorption.  Stools 
containing  free  fatty  acid  globules  almost  always  contain 
also  many  fat  curds  and  a  great  deal  of  mucus.  In 
considering  fatty  acids  it  must  be  remembered  that 
formic,  acetic,  butyric,  lactic,  succinic  acid,  etc.,  are  fatty 
acids  or  derivatives  of  them,  as  well  as  stearic  and  oleic 
and  palmitic  acid.  Formic  acid,  acetic  acid,  etc.,  are 
lower  in  the  series,  more  irritating  to  the  mucous  mem- 
brane, and  soluble  in  the  watery  content  of  the  stool, 
not  appearing  on  microscopic  examination.  Stearic, 
oleic  and  palmitic  acids  are  very  complex  and  high  in 
the  series,  are  insoluble  in  water,  presenting  themselves 
as  oily,  colorless  globules,  and  are  easily  distinguishable 
as  red  or  orange  globules  when  stained  with  Sudan  III. 


MINOR  DISTURBANCES.  183 

In  examining  a  stool  for  fatty  acids,  we  look  only  for 
globules.  Finding  none,  we  presume  that  that  particular 
phase  of  fat  indigestion  is  not  present.  But  the  stool 
may  be  very  acid  from  the  presence  of  fatty  acids  lower 
in  the  series  that  do  not  form  globules  but  are  in  solu- 
tion, and  clinically  it  makes  little  difference  whether  the 
higher  or  lower  fatty  acids  are  present. 

Soap  Stools.  These  are  light  in  color,  large  and  dry, 
and  do  not  adhere  to  the  napkin.  They  are  seen  in 
feedings  in  which  cream  or  whole  cow's  milk  is  in  the 
excess  as  related  to  the  carbohydrate  content. 

Grover1  says  that  the  normal  soap  stool  contains  soap 
and  protein  matter,  the  proportion  varying  with  the  rela- 
tive amount  of  fat  and  protein  in  the  food.  If  the  fat 
in  the  formula  is  high  and  the  protein  low,  we  shall  get 
a  typical  soap  stool,  provided  there  is  no  indigestion. 
Such  a  soap  stool  is  formed  and  of  very  light  color. 
They  are  usually  dry  and  constipated.  Soap  stools 
rarely  number  more  than  two  a  day.  They  are  alkaline 
in  reaction,  sometimes  almost  neutral.  When  spread  out 
they  appear  smooth  and  dull.  On  microscopic  exami- 
nation, no  neutral  fat  or  fatty  acids  are  found;  but  on 
being  heated  with  acetic  acid,  almost  every  particle  of 
solid  matter  is  found  to  be  changed  to  globules  of  fatty 
acids,  formed  from  the  soaps.  As  the  protein  in  the 
food  is  increased  and  the  fat  decreased,  there  will  be 
found  more  and  more  solid  matter  on  the  slide,  that  will 
not  break  down  with  heat  and  acetic  acid.  This  raises 
the  question  of  the  value  of  the  microscopic  examination 
of  the  stool  for  soaps.  It  has  usually  been  considered 
that  when  the  microscopic  field  was  "loaded"  with  glob- 
ules, i.e.,* virtually  all  the  solid  matter  changed  to  glob- 
ules of  fatty  acids,  the  baby  was  not  taking  care  of  the 
fat  very  well,  or  might  be  on  the  edge  of  an  acute  ex- 
acerbation of  a  chronic  fat  intolerance.  If  the  baby 


Grover,  Joseph  I. :  Jour.  A.  M.  A.,  1921,  76,  365. 


184  INFANT    FEEDING. 

were  taking  a  formula  composed  of  3  per  cent,  of  fat 
and  1  per  cent,  of  protein,  we  should  expect  to  find  lit- 
tle else  besides  soaps  in  the  stool.  If  the  fat  in  the  food 
should  be  kept  at  3  per  cent,  and  the  protein  raised  to 
2.5  per  cent.,  we  should  get  a  different  picture  micro- 
scopically. We  should  find  that  only  one-third  or  one- 
half  of  the  solid  matter  was  changed  to  globules,  the 
remaining  solid  matter  being  derived  from  the  protein 
in  the  food.  Just  as  much  soap  will  be  passed  in  the 
day,  but  on  microscopic  examination  it  will  seem  much 
less  because  it  is  scattered  and  separated  by  the  increased 
amount  of  protein  matter.  Microscopic  examination  of 
a  stool  for  soaps,  without  considering  the  formula,  is 
just  as  misleading  as  trying  to  estimate  the  red  count  in 
a  fresh  blood  smear  by  comparison  with  the  white  cells 
without  first  having  made  a  white  count. 

Boiled  High  Casein,  Low  Fat  Mixtures.  These  stools 
are  most  typically  produced  when  any  fat-free  milk, 
which  has  been  boiled  from  three  to  five  minutes,  is 
fed  in  amounts  over  two  ounces  per  pound  of  body 
weight  and  in  the  presence  of  minimum  or  moderate 
amounts  of  sugar.  Their  consistency  may  be  soft  but 
more  frequently  they  are  quite  solid  and  have  a  tendency 
to  dry  out  rapidly.  They  usually  have  a  greenish  tinge, 
shading  to  light  brown.  When  fat- free  lactic  acid  milk 
is  used  in  place  of  sweet  skim  milk  they  are  somewhat 
more  of  a  brownish  shade.  Grover  has  called  attention 
to  the  very  characteristic  shiny  surface  produced  when 
a  tongue  depressor  or  spatula  is  passed  through  it.  This 
sheen  must  be  differentiated  from  the  glistening  appear- 
ance of  mucus  and  also  from  the  natural  moisture  of  all 
normally  passed  stools,  due  to  their  watery  content.  The 
high  protein  stool  is  dull  on  the  outside,  where  it  is  dry 
from  contact  with  the  napkin  and  in  this  respect  greatly 
resembles  the  soap  stools. 

As  the  fat  in  the  diet  is  increased  the  greenish  color 
and  transparency  soon  disappear  and  with  further  in- 


MINOR  DISTURBANCES.  185 

crease  in  the  fat  the  smoothness  and  gloss  are  lost,  and 
when  the  fat  outweighs  the  protein  the  dull  soap  stool 
appears.  The  high  casein  stool  described  should  be  con- 
sidered a  normal  one  when  feeding  large  quantities  of 
boiled  skim  milk.  As  stated,  the  characteristic  appear- 
ance changes  directly  with  the  amount  of  carbohydrate 
and  fat  added. 

In  the  presence  of  an  excess  of  fat  and  protein  in  the 
stool,  upon  heating  with  acetic  acid  and  then  staining 
with  Sudan  III,  the  soaps  are  changed  into  fatty  acid 
globules,  while  the  protein  is  seen  as  solid  matter  that 
is  not  affected  by  the  heat  and  acid. 

Carbohydrate  Stools.  Starches  are  readily  stained 
with  dilute  tincture  of  iodine  or  Lugol's  solution.  The 
particles  of  undigested  starch  stain  blue  or  black.  Stools 
containing  much  fermented  starch  are  loose,  acid,  light 
brown,  and  excoriating,  and  contain  much  mucus.  In 
fact,  these  stools  are  often  mistaken  for  mucus.  This 
type  of  stool  is  most  likely  to  be  found  in  babies  having 
indigestion  from  certain  of  the  starchy  proprietary  foods. 
Small,  brownish  specks  are  often  found  in  normal  stools, 
representing  the  indigestible  cellulose  envelops  of  cereal 
foods. 

Indigestion  of  sugar  presents  no  typical  stool.  Stools 
resulting  from  sugar  fermentation  are  frequent,  very 
acid  and  excoriating,  and  often  watery.  The  solid  parts 
are  usually  full  of  small  air  bubbles,  formed  by  the 
chemical  decomposition.  These  may  be  demonstrated  by 
pressing  out  some  of  the  stool  between  a  slide  and  cover 
glass  and  examining  with  the  low  power.  The  stools 
are  usually  green  because  of  the  action  of  the  acids  on 
the  bile  pigments.  Stools  from  sucrose  or  lactose  fer- 
mentation are  green,  while  those  from  maltose-dextrin 
preparations  are  brown. 


186  INFANT    FEEDING. 

5.  Milk  Idiosyncrasy. 

A  few  infants  show  a  true  idiosyncrasy  to  cow's  milk, 
which  is  overcome  only  with  great  difficulty,  even  when 
the  milk  is  carefully  modified.  The  true  cause  of  this 
condition  is  still  in  dispute.  However,  it  may  be  said 
that  some  of  these  cases  are  undoubtedly  due  to  anaphy- 
laxis.  On  the  other  hand,  some  of  them  are  undoubtedly 
not  explained  on  this  basis.  Infants  suffering  from  such 
idiosyncrasy  will  usually  refuse  the  milk,  and  when  it  is 
forced  upon  them  it  results  in  vomiting,  diarrhea,  and 
frequently  an  urticario-erythematous  rash.  Cow's  milk 
feeding  in  these  cases  is  often  associated  with  a  low- 
grade  fever.  The  symptoms  speedily  subside  upon  the 
administration  of  castor  oil  and  the  withdrawal  of  milk. 
This  class  of  cases  offers  great  difficulty  in  feeding  during 
the  first  year  of  life,  as  carbohydrates  must  necessarily 
form  a  considerable  portion  of  their  diet.  Broths,  cooked 
cereals,  and  vegetable  purees  should  be  gradually  added 
to  the  diet  as  soon  as  they  can  be  digested. 

Replacing  the  cow's  milk  in  the  diet  by  goat's  milk 
will,  in  many  cases,  relieve  all  symptoms. 


CHAPTER    II. 

GENERAL   CONSIDERATION   OF   NUTRITIONAL 
DISTURBANCES. 

Evolution  of  the  Conception  of  Nutritional 
Disturbances. 

OUR  ideas  on  this  subject  have  undergone  considerable 
change  during  the  past  few  years.  Older  authors  viewed 
the  nutritional  disturbances  as  conditions  limited  to  the 
stomach  and  bowel,  and  likened  them  to  similar  condi- 
tions in  the  adult,  with  the  exception  that  more  serious 
results  were  to  be  expected  in  the  infant  because  of  the 
slight  physiological  resistance,  the  infant's  body  being 
more  favorable  to  a  severer  course. 

For  many  years  the  classification  of  Widerhofer,  of  the 
Vienna  school,  first  published  in  1880,  and  based  on  an 
anatomico-pathological  basis  was  the  one  in  general  use. 
These  conditions  he  grouped  as  follows : 

1.  Functional  disturbances,  as  acute  and  chronic  dys- 
pepsias. 

2.  Enterocatarrhs,   with  more  or  less   marked  histo- 
logical  changes  and  clinical  findings. 

3.  Follicular  enteritis,  with  deep-seated  inflammatory 
and  ulcerative  changes,  especially  in  the  large  intestine. 

4.  Cholera  infantum  (this  latter,  a  severe  type  of  en- 
terocatarrh,  was  classed  as  a  distinct  clinical  entity). 

Clinical  observation  soon  convinces  one  that  the  cases 
do  not  follow  the  distinct  types  in  the  above  classification, 
mixed  and  progressive  types  being  the  rule.  In  many  in- 
stances far-reaching  after-effects  remain,  and,  again,  in 
others  of  the  severest  types  few  if  any  anatomical  lesions 
are  demonstrable  at  autopsy.  Especially  in  young  in- 
fants we  find  marked  and  often  general  disturbances  fol- 
lowing in  the  wake  of  what  seemingly  were  localized  gas- 

(187) 


188  INFANT   FEEDING. 

tro-intestinal  lesions,  with  the  result  that  the  systemic  and 
not  the  intestinal  symptoms  were  of  more  serious  import. 
Again,  we  know  that  many  findings  formerly  attributed  to 
invasion  of  bacteria  or  their  toxins  can  now  be  at- 
tributed directly  to  improper  metabolism  of  the  food 
ingested. 

Food  Injuries.  The  nomenclature  covering  this  sub- 
ject has  also  changed,  and  we  now  adopt  the  term 
"Nutritional  Disturbances"  in  place  of  "Gastro-intestinal 
Diseases,"  the  former  covering  the  functional  and  ana- 
tomical disturbances,  as  well  as  the  bacterial  and  food 
traumas.  It  is,  however,  necessary  in  order  to  justify 
the  newer  nomenclature  to  look  upon  nutritional  disturb- 
ances not  as  localized  in  the  gastro-intestinal  canal,  but 
as  general  affections  involving  the  whole  organism  in  one 
of  the  most  vital  of  its  functions.  The  gastro-intestinal 
symptoms  form  only  a  part  of  the  clinical  picture ;  there- 
fore, in  its  fullest  conception  the  mental  state,  weight 
disturbances,  changes  in  the  temperature,  pulse,  respira- 
tion, etc.,  may  become  as  important  in  their  interpreta- 
tion as  the  diarrhea.  Two  schools  of  pediatrics  have 
given  us  the  nucleus  for  our  present  views  on  nutritional 
disturbances  and  their  classification — those  of  Czerny  and 
Finkelstein.  Czerny's  work  antedated  that  of  Firikel- 
stein  by  several  years,  and  he  based  his  classification  on 
what  he  considered  injuries  due  to  overfeeding  with  in- 
dividual food  elements.  These  he  called  "food  injuries," 
and  described  them  as  due  to  fat,  starch,  sugar,  protein, 
and  salts,  individually  or  in  combination,  either  when 
given  in  excess,  or  when  given  to  an  infant  with  lowered 
tolerance  for  these  food  elements. 

Finkelstein  viewed  the  nutritional  disorders  from  a 
broader  standpoint.  He  considered  them  "as  the  gradual 
development  of  an  increasing  intolerance  for  food" — 
step  by  step,  from  the  mildest  disturbances,  in  which  the 
only  striking  symptom  is  failure  to  gain  in  weight, 
through  the  severer  diarrheas,  up  to  the  final  stage  of 


NUTRITIONAL   DISTURBANCES  189 

intoxication,  when  the  infant  is  in  a  state  of  "metabolic 
bankruptcy."  In  his  classification  we  see  one  increasing 
process,  the  important  factor  of  which  is  found  in  the 
fact  that  the  infant  can  tolerate  less  and  less  food,  until 
finally  any  food  in  any  amount  acts  harmfully.  The 
stages  of  the  various  disorders  under  the  Finkelstein 
classification  must  therefore  necessarily  merge  gradually 
into  one  another,  and  lack  in  definiteness,  and  at  times 
present  a  picture  so  complicated  that  an  exact  diagnosis 
as  to  the  stage  be  temporarily  impossible. 

The  schools  of  Czerny  and  Finkelstein  laid  the  prac- 
tical foundation  for  the  combined  etiologic  and  clinical 
classifications  which  form  the  working  basis  for  our 
present  grouping  of  nutritional  disturbances.  The  no- 
menclature of  Finkelstein  applied  to  the  groups  in  his 
clinical  classification,  namely  Disturbed  Metabolic  Bal- 
ance, Dyspepsia,  Decomposition  and  Intoxication,  except 
for  the  latter,  give  the  clinician  very  little  insight  into 
the  underlying  etiologic  causes.  In  the  first  two  editions 
of  this  book,  the  Finkelstein  terminology  was  used,  but 
in  this  third  edition  the  more  descriptive  terms. 

Overfeeding  with  Cow's  Milk  with  Insufficient  Carbo- 
hydrates replaces  the  Disturbed  Metabolic  Balance. 

Nutritional  Disturbances  Characterised  by  Diarrhea 
replaces  Dyspepsia. 

Athrepsia  and  Marasmus  replace  Decomposition. 

Anhydremic  Intoxication  replaces  Intoxication. 

Before  entering  upon  a  general  discussion,  it  may  be 
wise  to  review  some  of  the  theories  promulgated  for  the 
advantages  of  human  over  cow's  milk  in  infant  feeding. 
Biedert  believed  that  the  decomposition  products  of  ^pro- 
tein digestion  were  the  important  factors.  This  idea  has 
not  been  substantiated  clinically.  Hamburger  advanced 
the  idea  that  the  albumins  foreign  to  the  human  body 
contained  in  cow's  milk  were  important  factors.  This 
is  true  in  a  limited  number  of  cases  of  milk  idiosyncrasy. 
Czerny  believed  that  the  fat,  and,  again,  the  sugar,  are 


190  INFANT   FEEDING. 

the  important  factors.  L.  F.  Meyer  believed  that  the 
whey  content,  and  more  especially  the  high  salt  content 
of  whey  (0.75  per  cent,  as  compared  with  0.2  per  cent, 
in  human  milk),  predisposed  to  intestinal  injury,  follow- 
ing which  trauma,  fats  and  sugars  play  an  important  part. 
Marfan,  Escherich,  Pfaundler,  and  others  believed  that 
specific  protective  bodies  of  unknown  nature  were  con- 
tained in  raw  human  milk,  which  are  of  vast  importance 
as  immunizing  bodies. 

Etiology.  In  the  proper  consideration  of  the  nutri- 
tional disturbances  we  must  consider  the  whole  organism 
rather  than  an  individual  organ  or  system  of  organs,  in 
formulating  our  diagnosis  and  outlining  a  course  for 
treatment.  In  past  years  the  tendency  has  been  to  con- 
sider the  gastro-intestinal  disturbances  as  conditions 
limited  to  these  organs  without  due  consideration  of  the 
systemic  involvement,  both  preceding  and  following  in 
the  wake  of  traumata  which  primarily  affected  the  di- 
gestive tract.  It  is  also  to  be  remembered  that  when  we 
have  an  involvement  of  the  gastro-intestinal  tract,  that 
only  rarely  is  the  underlying  pathological  condition 
limited  to  a  single  segment,  but  that  much  more  fre- 
quently the  entire  tract,  including  as  well  the  accessory 
digestive  organs,  are  likely  to  be  involved. 

In  the  study  of  a  given  case  it  is  first  necessary  to 
decide,  if  possible,  as  to  whether  it  is  a  mild  or  a  seri- 
ous disturbance.  This  is  of  greatest  importance  from 
both  the  standpoint  of  prognosis  and  treatment. 

To  form  a  definite  conclusion  we  must  consider  the 
age  of  the  infant,  realizing  that  the  age  at  which  the 
infant  becomes  sick  is  of  great  importance,  the  previ- 
ous history  of  the  infant  as  to  diet  and  preceding  nu- 
tritional disturbances  and  infections,  together  with  a 
careful  study  of  any  existing  constitutional  anomalies  or 
idiosyncrasies.  In  the  consideration  of  the  latter  the 
family  history  as  to  serious  nervous  diseases,  tubercu- 
lous infections,  and  the  history  of  the  result  of  previous 


NUTRITIONAL  DISTURBANCES.  191 

pregnancies,  are  of  extreme  importance.  Full  considera- 
tion must  be  given  to  the  surroundings  under  which  the 
nutritional  disturbance  developed.  Unhygienic  conditions 
in  the  home  are  of  the  greatest  importance.  It  is  also 
well  known  that  a  greater  tendency  exists  to  develop- 
ment of  this  class  of  disturbances  during  long  continued 
hospital  and  institutional  confinement  because  of  ex- 
posure to  infection  and  lack  of  exercise.  The  season 
of  the  year  should  be  considered  in  arriving  at  a  con- 
clusion as  to  the  underlying  etiology. 

According  to  the  school  affiliation  of  the  physician, 
one  speaks  of  food  injuries,  basing  his  classification  upon 
the  etiological  factor,  while  the  other  classifies  them  in 
the  clinical  light.  Almost  every  year  brings  with  itself 
new  modifications  in  the  presentation  of  the  subject. 
Many  of  them  do  not  lead  to  the  goal  of  the  practical. 

The  clinical  pictures  which  the  nutritional  disturbances 
of  infants  assume  in  their  course  are,  to  a  certain  extent, 
uniform,  and  in  fact  they  can  usually  be  included  in  cer- 
tain definite  types.  On  the  one  hand  are  the  acute  and 
subacute  disturbances,  of  which  the  most  important 
symptoms  are  related  to  the  gastro-intestinal  canal, 
especially  diarrhea  with  a  tendency  to  more  or  less  gen- 
eral disturbance,  more  particularly  of  the  nervdus  system. 
In  many  of  the  chronic  disturbances,  manifestations  on 
the  part  of  the  digestive  tract  may  be  entirely  absent, 
and  they  almost  never  present  a  characteristic  impression 
of  the  primary  etiological  factor.  All  of  them  have  in 
common,  signs  of  lowered  immunity,  abnormal  behavior 
of  the  weight  curve,  alterations  of  the  color  and  turgor 
of  the  skin.  In  fact  the  differences  are  likely  to  be  quan- 
titative only. 

Thus,  in  both  acute  and  chronic  disturbances  there  are 
often  very  narrow  limitations  for  the  etiological  diag- 
nosis, based  upon  clinical  findings.  And  it  is  often  dif- 
ficult to  determine  whether  alimentary  causes  due  to 
over-  or  underfeeding,  recurrent  infections  or  constitu- 


192  INFANT   FEEDING. 

tional  inferiority  are  the  underlying  factors.  Knowing 
these  limitations  the  importance  of  a  carefully  taken  his- 
tory cannot  be  overestimated.  The  history  of  the  pro- 
dromes, onset  and  development  will  frequently  give  the 
data  necessary  to  differentiate  between  the  primary  ali- 
mentary disturbances  and  those  secondary  to  infections 
and  constitutional  anomalies. 

All  of  the  etiological  possibilities  are  exhausted  by 
(1)  alimentation,  (2)  infection,  (3)  constitution,  and 
(4)  environment  (weather  and  hygiene).  Their  sharp 
differentiation,  however,  is  often  difficult. 

And  while  a  proper  estimation  of  the  degree  of  the 
nutritional  disturbance  may  be  gained  from  the  history 
(determination  of  the  preceding  illnesses  and  the  deter- 
mination of  the  development  history  of  the  present  ill- 
ness), a  detailed  study  of  the  actual  picture,  as  pre- 
sented in  the  individual  infant,  as  met  by  the  physician 
in  his  daily  practice,  must  form  the  basis  for  properly 
outlining  the  course  of  treatment. 

Even  in  those  nutritional  disturbances  in  which  the 
etiological  diagnosis  is  not  only  probable,  but  positive, 
the  treatment  is  not  based  upon  the  etiology,  but  rather 
upon  condition  of  the  individual  infant  at  the  time  of 
examination.  Thus,  if  proper  treatment  of  a  case  pre- 
senting diarrhea  as  the  most  marked  symptom,  was  pos- 
sible only  after  we  had  the  knowledge  of  the  factors, 
which  produced  the  diarrhea,  the  institution  of  proper 
therapy  would  in  many  instances,  of  necessity,  be  delayed. 

On  the  other  hand,  there  are  diseases,  although  symp- 
tomatically  almost  completely  alike,  varying  widely  in 
their  course  and  response  to  the  same  treatment  and  in 
their  final  outcome.  In  other  words,  the  individuality 
of  the  infant  is  often  the  deciding  factor  in  the  prog- 
nosis of  the  case. 

By  exact  clinical  analysis  we  are  able  in  most  cases 
to  arrive  at  a  proper  estimation  of  the  degree  of  the 
nutritional  disturbance  and  thus  to  the  institution  of  the 


NUTRITIONAL  DISTURBANCES.  193 

plan  of  treatment,  and  this  object  may  be  reached  in 
almost  every  case  by  a  study  of  the  preceding  history 
of  the  infant  and  by  a  consideration  of  the  progress  of 
the  disturbance. 

We  know  that  the  bacteria  and  their  products  as  en- 
countered in  the  food  administered,  are  less  often  the 
offending  factors  than  formerly  supposed,  and  that  im- 
proper food,  either  quantitatively  or  qualitatively,  is  of 
equal  or  greater  importance  in  the  causation  of  nutri- 
tional disturbances.  To  avoid  confusion  in  our  discus- 
sion of  this  vast  field,  we  will  first  consider  food  injuries 
and  discuss  the  infections  incidentally,  as  they  affect  the 
former,  and  at  a  later  period  discuss  the  infections  in 
their  relation  to  the  nutritional  disturbances  more  in 
detail. 

From  the  foregoing  it  becomes  evident  that  to  discuss 
the  whole  subject  properly  it  becomes  necessary  to  con- 
sider them  from  both  the  etiological  and  the  clinical 
standpoints. 

ETIOLOGICAL  CLASSIFICATION  OF  NUTRITIONAL 
DISTURBANCES. 

1.  Overfeeding  tvith  Milk  Mixtures,  of: 

(a)  Correct    composition     (too    frequent    or    too 

much). 

(b)  Incorrect  composition: 

(l)i  With  insufficient  sugars. 
(2)  With  excess  of   fat,  protein,  sugar  or 
salt. 

(c)  Raw   milk    (with   resulting   mechanical    irrita- 

tion due  to  large,  hard  protein  curds). 

2.  Underfeeding  innik  Milk  Mixtures  of  Correct  Compo- 

sition. 

3.  Underfeeding  with  Diets  of  Incorrect  Composition. 

(a)  Diets    with     insufficient    milk     and     sufficient 
sugars. 

13 


194  INFANT   FEEDING. 

(b)  Diets  composed  chiefly  or  entirely  of  starches. 

(c)  Diets  low  in  vitamines. 

Jf.  Feeding  with  Spoiled  Milk  (Decomposition  Products 

of  Milk  and  Bacterial  Toxins). 
5.  Subnormal  Food  Tolerance. 

(a)  Preceding  dietetic  errors  and  nutritional  dis- 

turbances. 

(b)  Infections: 

(1)  Enteral:  dysentery,  typhoid,  etc. 

(2)  Parenteral:     otitis,    pharyngitis,    pneu- 

monia, pyelitis,  etc. 

(c)  Extremes    of    temperature    (heat    of    summer 

and  cold  of  winter). 

(d)  Improper    hygienic   conditions   and    "hospital- 

ism." 

(e)  Constitutional  anomalies: 

(1)  Organic   (pyloric  stenosis,  megacolon). 

(2)  Functional  (idiosyncrasy  to  cow's  milk. 

Exudative    diathesis.       Neuropathic 
diathesis.) 

Nutritional  Disturbances  Due  to  Overfeeding.  This 
is  one  of  the  most  important  of  all  etiological  factors. 
The  disturbance  may  be  due  to  a  diet  of  correct  compo- 
sition, but  quantitatively  too  great  for  the  individual  case, 
or  a  diet  with  an  excessive  amount  of  one  or  more  con-' 
stituent  ingredients. 

Nutritional  Disturbances  Following  Underfeeding. 
We  recognize  two  types:  (1)  Qualitative,  and  (2)  quan- 
titative. Sooner  or  later  the  results  are  similar.  The 
former  diets,  qualitatively  wrong,  are  frequently  seen 
where  the  caloric  requirements  are  met,  but  one  or  more 
of  the  necessary  food  elements  is  insufficient.  An  ex- 
ample of  this  is  seen  in  the  feeding  of  carbohydrate  rich 
food,  as  condensed  milk,  malted  milk,  etc.  When  the 
minimum  requirements  for  growth  and  development,  at 
least  for  both  organic  and  inorganic  salts,  are  met  in  such 


NUTRITIONAL  DISTURBANCES.  195 

a  diet,  the  organism  may  be  able  to  overcome  the  excess 
of  one  ingredient,  but  if  this  is  not  true,  sooner  or  later 
some  grave  complications  will  result.  With  diets  com- 
posed largely  of  cereals  or  cereal  waters,  as  is  frequently 
seen  when  these  are  used  to  replace  the  milk  mixtures, 
in  the  course  of  diarrheal  disturbances,  the  clinical  pic- 
ture of  inanition  develops  with  great  rapidity.  When  we 
feed  less  than  a  sustaining  diet  of  32  calories  per  pound 
body  weight  or  70  calories  per  kilogram,  there  soon  re- 
sults a  quantitative  inanition  with  all  its  undesirable  after 
effects.  More  recently  we  have  learned  to  classify  in- 
fants fed  for  prolonged  periods  on  diets  low  in  vitamines 
among  those  suffering  from  qualitative  inanition.  To 
judge  such  errors  in  diet,  each  individual  infant  must  be 
studied  as  a  distinct  entity. 

Nutritional  disturbances  following  feeding  with 
spoiled  milk  may  be  due  to  decomposition  products  of 
milk,  bacterial  toxins  or  pathogenic  organisms  contained 
in  the  milk  which  may  result  in  secondary  enteral  or 
parenteral  infections. 

Nutritional  Disturbances  Due  to  Subnormal  Food 
Tolerance.  Many  factors  can  cause  such  a  state  of 
affairs.  The  history  of  preceding  dietetic  errors  and  nu- 
tritional disturbances  should  be  given  careful  considera- 
tion. Thus,  e.g.,  diarrheal  conditions,  due  to  a  given 
cause,  will  in  the  normal  infant  give  a  far  better  prog- 
nosis than  in  the  infant  which  has  suffered  from  over- 
or  underfeeding,  while  in  the  athreptic  infant  even  mod- 
erate diarrheal  disturbance  should  give  grave  concern. 

Infections,  enteral  and  parenteral  will  show  marked 
individual  differences  in  producing  a  subnormal  food 
tolerance.  The  natural  immunity  of  the  healthy  breast- 
fed infant  affords  the  best  example  of  the  importance 
of  a  diet  in  the  establishment  of  resistance  to  infection. 
The  susceptibility  to  infection  is  increased  by  every 
nutritional  disturbance  as  well  as  by  constitutional 
inferiority. 


196  INFANT   FEEDING. 

Most  of  the  disturbances  due  to  extremes  of  tempera- 
ture are  noted  in  summer,  during  which  season  they  are 
not  only  due  to  the  effect  of  temperature  upon  the  infant, 
but  also  due  to  spoiled  food.  Exposure  to  cold  is  often 
an  etiological  factor  through  lowering  of  immunity. 

Improper  hygienic  conditions  in  the  home  predis- 
pose to  impairment  of  digestive  functions  as  well  as  to 
secondary  infections.  In  this  connection  it  should  be 
remembered  that  long  continued  hospitalization,  even  in 
the  presence  of  good  surroundings  and  proper  diet,  may 
result  in  lowered  food  tolerance  due  to  lack  of  "mother- 
ing" and  exposure  to  infection. 

Constitutional  anomalies  may  result  in  various  types 
of  nutritional  disturbances,  depending  upon  their  nature. 
In  the  presence  of  hypertrophic  pyloric  stenosis,  quan- 
titative inanition,  with  resulting  athrepsia,  is  likely  to 
develop  in  uncorrected  cases.  In  the  presence  of  intes- 
tinal stasis,  due  to  a  weakened  intestinal  musculature, 
as  seen  in  megacolon,  and  in  the.  course  of  severe  rickets, 
a  marked  constipation  develops,  with  retention  of  the 
intestinal  contents  for  a  prolonged  period,  both  in  the 
ileum  and  large  intestine,  with  resulting  absorption  of 
the  products  of  decomposition.  Fortunately  few  infants 
show  a  true  idiosyncrasy  to  cow's  milk.  This  causes  very 
great  difficulty  in  feeding  young  infants  in  the  absence 
of  a  supply  of  breast  milk.  The  intolerance  of  infants 
suffering  from  exudative  diathesis,  to  overfeeding  as 
well  as  the  tendency  of  neuropathic  infants  to  develop 
exaggerated  reflex  action  in  the  gastro-intestinal  tract, 
with  resulting  cardio-  or  pylorospasm,  and  increased 
peristalsis  of  the  intestinal  tract  with  the  development 
of  colic  and  diarrhea,  offer  some  of  the  most  difficult 
problems  in  infant  feeding.  This  group  of  cases  calls 
for  repeated  observation  and  study  of  the  individual 
infant. 


NUTRITIONAL  DISTURBANCES.  197 

General  Symptomatology. 

The  normal  healthy  infant,  with  a  well-balanced  metab- 
olism, reacts  to  food  as  follows : 

1.  An  elastic,  pink  skin,  a  well-developed  panniculus 
adiposus,    well-colored    mucous    membrane.      Its    tissues 
should  feel  firm. 

2.  One  should  expect  certain  muscle  and  bone  develop- 
ment according  to  the  age  of  the  infant. 

3.  A  uniform  rectal  temperature  (98  to  99  degrees  F.), 
almost  a   monothermia.     Any   considerable   deviation   is 
abnormal. 

4.  It  should  show  a  regular,  steady  gain  in  weight. 

5.  The  bowel  movements  should  be  regular,  and  should 
vary  with  the  food  ingested. 

6.  Its   disposition    should   be   happy,   and   its   nervous 
functions  normal.     It  should  sleep  well,  and  be  satisfied 
with  feedings  at  three-  to  four-hour  intervals. 

7.  It  should  show  a  wide  tolerance  for  food,  both  as 
to  the  diet  as  a  whole,  and  to  the  individual  food  ele- 
ments. 

8.  Renal,  circulatory  and  respiratory  functions  should 
be  normal. 

Bearing  in  mind  the  attributes  of  the  healthy  infant, 
we  are  now  in  a  position  to  review  the  factors  leading 
to  and  influencing  our  present  conceptions  of  the  nutri- 
tional disturbances,  based  on  an  ascending  series  of 
pathological  stages  in  those  infants  whose  tolerance  for 
food  has  been  overstepped,  either  because  of  overfeeding 
or  because  of  diminished  or  abnormal  tolerance  on  the 
part  of  the  baby  itself. 

The  clinical  observation  soon  convinces  one  that  while 
simple  types  are  not  uncommon,  mixed  and  progressive 
types  are  of  frequent  occurrence.  Exact  observation  of 
variations  in  the  general  condition  of  the  infant  and  the 
correct  interpretation  are  necessary  for  a  proper  under- 
standing of  the  clinical  symptoms.  A  correct  diagnosis 


198  INFANT   FEEDING. 

of  a  condition  can  usually  be  made  from  the  clinical 
analysis  of  the  symptoms  with  the  aid  of  the  previous 
history.  In  order  to  outline  the  proper  plan  of  treat- 
ment, it  is  necessary  to  decide  whether  in  a  case  under 
observation  there  is  a  mild  or  a  serious  disturbance. 
This  is  of  the  greatest  importance  in  the  choice  of  good 
mixtures,  both  in  qualitative  and  also  in  quantitative  re- 
spect. The  physician  needs  to  learn  that  the  condition 
of  the  infant  should  not  be  estimated  by  any  single  clini- 
cal symptom,  but  rather  according  to  the  effect  upon  the 
general  condition  of  the  patient.  He  must  take  into  con- 
sideration the  weight  curve,  the  color  of  the  skin,  the 
muscle  tone  and  turgor,  the  presence  of  anemia,  the  state 
of  the  sensorium,  and  the  condition  of  the  stools,  and 
in  addition  to  these  any  other  symptoms  which  may  de- 
velop. As  an  example,  he  should  not  consider  only  the 
presence  of  diarrhea,  but  even  more  important,  the  re- 
action of  the  infant  to  the  loss  of  body  fluids  and  salts 
through  excessive  stools.  He  should  remember  that  age 
is  an  important  factor  and  tha.t  nutritional  disturbances 
in  the  first  three  months  of  life  should  always  be  re- 
garded as  serious,  in  other  words,  a  diarrheal  condition 
in  the  first  six  weeks  of  life  is  far  more  serious  than 
the  one  developing  in  the  sixth  month  of  life.  The  dis- 
turbance in  the  infant  whose  history  shows  that  there 
is  nothing  defective  in  his  constitution,  allows  of  a  bet- 
ter prognosis  than  would  be  expected  in  a  weakling.  By 
exact  clinical  analysis  we  are  able  in  most  cases  to  ar- 
rive at  a  proper  estimation  of  the  degree  of  nutritional 
disturbance  and  thus  to  institute  a  plan  for  treatment. 

CLINICAL  CLASSIFICATION  OF  NUTRITIONAL 
DISTURBANCES. 

In  the  clinical  pictures  that  may  develop  on  the  basis  of 
the  above-mentioned  etiology,  several  more  or  less  dis- 
tinct types  or  syndromes  may  be  differentiated.  These 


NUTRITIONAL  DISTURBANCES.  199 

may  be  dependent  primarily  or  exclusively  upon  the  die- 
tetic errors,  or  they  may  be  influenced  by  secondary  etio- 
logical  factors.  The  degree  of  reaction  depends  upon 
the  extent  to  which  the  infant's  metabolism  is  disturbed. 
For  practical  purposes  of  diagnosis  and  treatment  the 
nutrition  disturbances  may  be  grouped  on  a  clinical  ba- 
sis, as  follows : 

1.  Nutritional  Disturbances   Unassociated  with  Diar- 
rhea. 

2.  Nutritional    Disturbances    Characterised    by    Diar- 
rhea.    (Diarrheal  disturbances.) 

3.  Athrepsia   (Marasmus.     Decomposition). 

4.  Anhydremia    (Anhydremic  intoxication.     Intoxica- 
tion.) 

These  types  represent  stages  in  the  course  of  nutri- 
tional disturbances  and  one  form  may  lead  rapidly  into 
another,  if  the  errors  in  the  diet  are  not  remedied,  or 
when  secondary  complications,  such  as  infections,  arise. 


CHAPTER  III. 

NUTRITIONAL  DISTURBANCES  UNASSOCIATED 
WITH  DIARRHEA. 

Overfeeding  with  Cow's  Milk  with  Insufficient 
Carbohydrates. J 

THE  syndrome  to  be  described  under  this  cause  ap- 
pears in  the  pediatric  literature  under  various  synonyms. 
Among  them  are  the  following: 

Disturbed  metabolic  balance,  weight  disturbance,  mal- 
nutrition, hypothrepsia  (Parrott),  hypotrophy  (Lang- 
stein),  fat  constipation,  bilanzstoerung  (Finkelstein), 
piilchnahrschaden  ( Czerny-Keller  ) . 

This  nutritional  disturbance  is  due  to  administration 
of  cow's  milk  mixtures  in  which  the  error  is  based  upon 
an  excess  of  cream  or  milk  in  the  diet  in  the  presence 
of  an  insufficiency  of  sugar.  A  disturbance  in  the 
metabolic  balance  is  rarely  seen  in  the  previously  nor- 
mal infant  until  the  amount  of  cow's  milk  fed  is  in  ex- 
cess of  two  ounces  (60  mils)  per  pound  body  weight. 
With  this  amount  of  milk  the  average  requirement  in 
sugar  to  be  added  will  be  one-tenth  ounce  (3.0  Gm.) 
for  each  pound  of  the  infant's  weight.2  The  clinical 
signs  develop  slowly  in  most  cases  and  follow  a  period 
of  good  progress  which  ceases  more  or  less  abruptly. 
Among  the  early  signs  are  a  general  retardation  of  de- 
velopment, associated  with  a  loss  of  body  turgor  and 
stationary  weight.  The  severity  of  the  clinical  picture 
will  depend  upon  the  ability  of  the  individual  infant  to 

1  In  the  first  and  second  editions  these  cases  were  described 
under  the  title  of  Disturbed  Metabolic  Balance. 

52  It  should  be  remembered  that  a  well-balanced  24  hour  diet 
for  an  infant  should  rarely  contain  more  than  one  quart  (1000 
mils)  of  cow's  milk  and  from  1%  to  2  ounces  of  sugar  (45  to 
60  Gm.).  Further  nutritional  requirements  are  to  be  met  by 
the  addition  to  the  diet  of  foods  other  than  milk  and  sugar. 
(200) 


DISTURBANCES  WITHOUT  DIARRHEA.         201 

overcome  the  ill  effects  of  the  one-si'ded  diet  and  this 
will  vary  directly  with  the  degree  of  the  error  and  the 
time  over  which  the  diet  has  been  administered.  The 
diagnosis  must  be  based  on  the  presence  of  symptoms 
resulting  in  definite  injury  to  the  organism.  Not  infre- 
quently the  diagnosis  is  made  upon  the  presence  of 
marked  constipation  with  a  passing  of  soap  stools.  These 
are  dry  and  putty-like,  have  a  foul  odor  and  an  alkaline 
reaction.  It  must  be  emphasized  that  the  diagnosis  of 
this  nutritional  disturbance,  due  to  an  improperly  bal- 
anced cow's  milk  mixture,  must  not  be  based  upon  the 
presence  of  soap  stools  alone.  This  is  the  characteristic 
stool  seen  in  feeding,  even  when  the  milk  is  not  in  ex- 
cess of  the  amount  on  which  the  infant  will  make  normal 
progress. 

Etiology.  Artificially  fed  infants  are  chiefly  affected, 
probably  because  of  the  high  carbohydrate  and  low  pro- 
tein content  in  the  breast-milk. 

The  clinical  picture  presented  by  this  type  of  over- 
feeding, which  is  due  to  an  improperly  balanced  diet, 
is  usually  seen  in  infants  receiving  food  mixtures  com- 
posed of  cream  and  milk,  top^milk  or  whole  milk  with 
an  insufficiency  of  carbohydrates,  resulting  in  an  im- 
proper proportion  between  the  fat  and  carbohydrates  in 
the  diet.  In  the  presence  of  excessive  amounts  of  carbo- 
hydrates we  are  more  likely  to  see  a  diarrheal  condition. 
Proteins  also  play  an  important  role  in  the  causation  of 
the  clinical  picture  of  this  disease,  in  that  in  the  presence 
of  a  relative  overfeeding  with  proteins  an  alkaline  intes- 
tinal reaction,  necessary  to  the  production  of  fat-soap 
stools,  is  brought  about.  Not  all  infants  react  alike  to 
the  same  milk  mixture,  and  those  who  have  a  low  toler- 
ance for  milk,  as  is  the  case  with  many  of  the  infants 
suffering  from  exudative  diathesis,  develop  the  clinical 
picture  much  earlier  than  the  average  infant.  The  same 
may  be  said  of  the  lowered  food  tolerance  following  in- 
fections. Fortunately  in  these  infants  the  tolerance  for 


202  INFANT   FEEDING. 

carbohydrates  is  retained  and  therefore  the  fat  and  the 
protein  in  the  diet  can,  to  a  great  degree,  be  replaced  by 
sugar  and  cereals.  It  should  be  remembered  that  these 
infants  suffer  from  a  carbohydrate  poverty  or  deficiency 
and  therefore  in  the  presence  of  infections  and  other 
complications  there  is  an  urgent  indication  for  a  high 
carbohydrate  feeding. 

Pathogenesis.  As  soap  stools  are  so  frequently  re- 
garded as  the  basic  symptom  in  the  diagnosis  of  this  dis- 
turbance, their  significance  will  be  emphasized.  The 
soap  stool  must  be  viewed  as  an  effect  and  not  as  the 
cause.  The  condition  is  not  due  to  a  fat  indigestion,  but 
a  disturbance  in  salt  metabolism  based  on  an  improper 
composition  of  the  diet  in  which  there  is  a  relative  over- 
feeding with  fat  and  protein  in  the  presence  of  insuf- 
ficient carbohydrates.  The  stools  consist  largely  of  cal- 
cium and  magnesium  soaps  formed  from  the  fatty  acids. 
The  presence  of  the  relatively  large  amounts  of  calcium 
caseinate  in  cow's  milk  leads  to  an  alkaline  condition  in 
the  intestinal  tract  which  reaction  increases  the  tendency 
toward  their  formation.  These  stools  also  contain  large 
amounts  of  calcium  phosphate,  which  in  the  presence  of 
the  alkaline  reaction  of  the  intestinal  tract  are  rendered 
insoluble.  The  organism  may  be  markedly  affected 
through  the  lack  of  absorption  of  bases  and  excessive 
loss  of  alkalies  by  increased  intestinal  secretion.  Many 
infants  will  overcome  the  ill-effects  for  long  periods  of 
time  without  clinical  evidence.  Others  will  present  evi- 
dences of  retarded  growth,  resulting  in  malnutrition. 
Rickets  may  result.  The  alkalies  most  involved  in  the 
formation  of  the  soap  stools  which  are  so  commonly  seen 
in  this  condition  are  calcium  and  magnesium.  There  is, 
however,  also  a  decreased  sodium  and  potassium  reten- 
tion, as  evidenced  more  especially  by  increased  excretion 
in  the  urine.  This  loss  of  calcium  and  magnesium 
through  the  stools  and  the  inability  to  retain  sodium  and 
potassium,  and  the  accompanying  decrease  in  water  re- 


DISTURBANCES  WITHOUT  DIARRHEA.         203 

tention,  soon  lead  to  weight  loss.  The  soap  stools,  as 
stated,  contain  an  excess  of  calcium  and  magnesium 
soaps,  and  less  fatty  acids  and  neutral  fats  than  is  seen  in 
the  normal  stools. 

To  obtain  such  a  stool,  there  must  be  a  strong  alkaline 
reaction  in  the  large  intestine,  and  the  food  elements  of 
the  diet  are  important  factors  in  the  production  of  this 
reaction. 

Fats.  An  excess  of  fats  in  the  food  leads  to  an  ex- 
cess of  fatty  acids  in  the  intestine,  with  a  tendency  to 
the  formation  of  an  acid  reaction  of  the  intestinal  con- 
tent. To  combine  with  these,  alkalies  are  withdrawn 
from  the  body,  if  insufficient  in  the  intestinal  tract. 

Proteins,  more  especially  an  excess  of  calcium  casein- 
ate,  cause  secretion  of  a  large  quantity  of  intestinal  juice 
which  is  alkaline.  This  in  time  tends  to  produce  an  al- 
kaline intestinal  reaction,  if  not  counteracted  by  exces- 
sive fermentation,  the  former  being  favorable  to  the 
formation  of  soap  stools.  In  all  probability  the  great 
calcium  content  of  cow's  milk  (4  to  1),  as  compared 
with  breast-milk,  also  offers  another  factor  in  the  ten- 
dency to  formation  of  calcium  soaps. 

Carbohydrates.  In  the  presence  of  sufficient  ferment- 
able carbohydrates  (disaccharides)  in  the  diet,  the  in- 
testinal reaction  becomes  acid,  the  products  of  fermen- 
tation counteracting  the  tendency  to  alkaline  reaction, 
and  thus  preventing  the  formation  of  fat-soap  stools. 

The  decreased  absorption  of  bases  and  the  increased 
withdrawal  of  alkalies  from  the  system  disturbs  the  acid- 
alkaline  equilibrium,  creating  a  relative  excess  of  acids. 
This  results  in  an  increased  production  of  ammonia  to 
counteract  the  loss,  of  alkali  in  order  to  prevent  acidosis. 

We  find  a  striking  example  of  a  paradoxical  reaction, 
namely,  increasing  the  food  (milk  or  fat)  makes  the 
condition  worse  and  causes  weight  loss,  while  diminish- 
ing the  milk  with  an  increase  in  carbohydrates  results 
in  return  to  normal. 


204  INFANT   FEEDING. 

The  clinical  picture  is  due  to : 

1.  Excessive  withdrawal  of  salts   from  the  body  tis- 
sues, due  to  fat  and  protein  overfeeding. 

2.  A  relative  insufficiency  of  carbohydrates. 

3.  Bacterial   decomposition   of    food   in  the  intestinal 
tract. 

As  previously  stated,  the  fat-soap  stools  must  not  form 
the  basis  for  diagnosis.  It  must  be  based  upon  the  study 
of  the  feeding  history,  clinical  signs  and  in  some  cases 
the  constitutional  anomalies  and  systemic  infections  as 
predisposing  causes.  On  the  whole,  this  clinical  syn- 
drome is  not  as  frequently  seen  as  might  be  expected, 
because  of  the  ability  of  the  infant  to  overcome  the 
dietetic  error  sufficiently  to  make  a  fair  progress. 

Symptoms.  There  is  a  retarding  of  development 
qualitatively  and  quantitatively,  the  infants  frequently 
being  undersized,  without  showing  marked  general  symp- 
toms of  disease. 

1.  W eight.    Notwithstanding  proper  or  even  excessive 
caloric  intake,  there  may  be  no  gain  in  weight,  or  an 
irregular  increase,  however,  under  the  normal.    (Station- 
ary weight  or  insufficient  gain  in  the  infant  corresponds 
to  a  loss  in  weight  in  the  adult.     Stationary  weight  in 
an  infant  alone  leads  to  the  picture  of  malnutrition  and 
marasmus.) 

2.  Temperature.     Usually    we   find    daily   oscillations 
from  1°  to  2°,  with  a  tendency  toward  subnormal. 

3.  The  child  is  restless. 

4.  Sleep  is  disturbed. 

5.  The  skin  is  pale,  with  loss  of  elasticity  and  turgor. 
Intertrigo  and  eczema  are  frequently  seen. 

6.  Muscles  are  soft  and  flabby. 

7.  Regurgitation  and  vomiting  are  frequent. 

8.  Abdomen,  tympanitic. 

9.  Stools.    In  excessive  milk  feeding  the  common  type 
is  the  fat-soap  stool,  which  is  foul-smelling,  dry,  light  in 
color  (gray  to  white),  friable,  and  does  not  stick  to  the 


DISTURBANCES  WITHOUT  DIARRHEA.        205 

napkin.  The  pale  color  is  due  to  the  reduction  of  biliru- 
bin  to  urobilinogen.  The  odor,  in  part  at  least,  is  due 
to  the  decomposition  of  protein.  The  large,  putty-like 
masses  of  stool  are  moved  through  the  lower  intestinal 
tract  with  difficulty,  even  in  the  presence  of  active  peri- 
stalsis. This  interferes  with  emptying  of  the  intestine, 
the  stools  becoming  very  dry  through  the  absorption  of 
moisture  due  to  this  long  period  of  retention.  Not  in- 
frequently their  progress  through  the  colon  is  associated 
with  colicky  pains.  In  the  presence  of  excessive  carbo- 
hydrates this  stool  may  be  lacking,  due  to  the  presence 
of  a  slight  intestinal  indigestion.  Occasionally  bacterial 
decomposition  of  the  proteins  may  cause  a  diarrhea. 

10.  Immunity  is  lessened  with  resulting  furunculosis 
and   susceptibility   to   respiratory,    gastro-intestinal,   and 
genito-urinary  infections. 

11.  Urine  is  usually  ammoniacal,  and  contains  an  ex- 
cess of  sodium  and  potassium  salts.    The  fact  that  alka- 
lies, found  as  soaps,  are  poorly  absorbed  from  the  intes- 
tine makes  it  necessary  for  the  body  to  produce  ammonia 
to  make  up  for  the  deficit  and  to  prevent  acidosis.    This 
explains  the  excess  of  ammonium  salts  in  the  urine.  The 
salts  are  decomposed  after  passage  of  the  urine  by  com- 
ing in  contact  with  bacteria.     The  freeing  of  ammonia 
by  the  bacterial  decomposition  can  be  prevented  by  rins- 
ing the  napkins  after  boiling  and  washing  in  a  %o>ooo 
solution  of  bichlorid  of  mercury,  the  deposited  mercurial 
salt  preventing  bacterial  growth  after  the  urine  comes 
in  contact  with  the  napkin.1 

Diagnosis.  Due  to  the  fact  that  this  type  of  stool 
with  associated  constipation  is  so  frequently  seen  in 
artificially  fed  infants,  it  is  difficult  to  say  just  when 
such  constipation  becomes  pathologic.  As  long  as  the 
infant  is  making  satisfactory  progress  and  showing  no 


1  Cooke,  J.  V. :  Etiology  and  Treatment  of  Ammonia  Dermati- 
tis of  the  Gluteal  Region  of  Infants,  Amer.  Jour.  Dis.  of  Children, 
xxii,  481.  1921. 


206  INFANT   FEEDING. 

signs  of  definite  pathology  the  mere  presence  of  soap 
stools  should  be  considered  as  of  relatively  slight  im- 
portance and  should  not  lead  to  radical  changes  in  the 
diet. 

The  diagnosis  must  be  based  on  the  clinical  picture 
and  feeding  history,  as  follows:  Sufficient  caloric  intake 
(100  calories  per  kilogram),  with  relative  excess  of  fat 
and  protein,  and  insufficiency  of  carbohydrates,  station- 
ary weight  or  insufficient  gain,  loss  of  turgor,  lack  of 
proper  development,  and  usually  soap  stools,  all  in  the 
absence  of  any  other  causative  factor.  Underfeeding 
and  all  past  illnesses  which  might  retard  development 
must  be  excluded. 

Prognosis  is  very  favorable  in  uncomplicated  cases, 
with  a  properly  instituted  diet.  In  the  average  case  two 
to  three  weeks  is  required  to  overcome  the  constipation, 
and  to  obtain  a  gain  in  weight.  Occasionally  a  severe 
type  is  seen  which  is  difficult  to  overcome,  most  com- 
mon in  infants  with  an  idiosyncrasy  to  cow's  milk. 

Complications.  Because  of  the  lowered  immunity, 
infections  are  common,  especially  of  the  nasopharynx, 
lungs,  middle  ear  and  skin  and  gastro-intestinal  and 
genito-urinary  tract.  Exudative  diathesis  is  not  an  un- 
common associated  condition. 

Sequelae.  This  condition  is  often  the  forerunner  of 
the  more  serious  nutritional  disorders,,  such  as  diarrhea, 
athrepsia,  and  anhydremia.  Chronic  constipation  fre- 
quently results,  due  to  the  atony  of  the  intestinal  wall 
and  abdominal  muscles.  Rickets  frequently  develops  in 
these  infants. 

Treatment.  To  institute  a  proper  treatment,  we 
must  remember  that  the  clinical  picture  is  not  dependent 
on  gastro-intestinal  findings  only,  but  also  on  an  abnor- 
mal intermediary  metabolism  (therefore  the  designation 
Disturbed  Metabolic  Balance),  and  that  fat  overfeeding 
primarily,  and  a  carbohydrate  insufficiency  secondarily, 


DISTURBANCES  WITHOUT  DIARRHEA.         207 

are  causative  factors,  and  that  protein  overfeeding  may 
be  an  important  element. 

1.  Diet  with  Human  Milk.    This  is  by  all  means  the 
best  treatment,  especially  in  young  infants.     Weight  in- 
crease may  be  slow  at  first,  probably  due  to  low  salt  and 
protein  content  of  human  milk.    A  loss  of  more  than  6 
to  10  ounces  over  a  period  of  three  or  four  days  is  fre- 
quently seen.    More  than  this  should  lead  one  to  suspect 
an  error  in  diagnosis.     This  loss  may  be  due,  as  stated, 
to  stopping  of  a  food  rich  in  proteins  and  salts,  and  sub- 
stituting one  low  in  the  same.     This  stage  is  passed  in 
about  four  days,  when  the  system  adapts  itself  to  the  new 
food  ingredients.    Temperature  and  pulse  do  not  change, 
and  the  stools  assume  a  breast-milk-stool  character.     If 
the  stage  of  reparation  is  slow,  and  the  child  does  not 
gain  in  weight,  the  substitution  of  one  meal  rich  in  pro- 
tein and  salts  daily  will  frequently  help  (buttermilk  or 
skim  milk).     Mother's  milk  also  helps  to  increase  the 
immunity. 

2.  Diet  with  Artificial  Foods.    In  pathogenesis  of  this 
condition  the  milk  plays  the  most   important   role,   and 
this  is  best  counteracted  by  replacing  it  in  part,  with  well- 
tolerated  carbohydrates. 

(1)  In  simple  cases  reduce  the  quantity  of  milk  and 

add  carbohydrates  in  the  form  of  sugar  and 
starches. 

(2)  In  severe  cases: 

(a)  Malt  soup  (Keller's)  (p.  437)  is  exceedingly 
valuable.  Malt  soup  is  indicated  in  the 
presence  of  fat-soap  stools  which  soon  be- 
come pasty  and  of  mahogany-brown  color; 
the  best  results  with  malt  soup  are  obtained 
in  infants  from  three  to  six  months  of  age. 
After  four  months  more  milk  than  given  in 
the  original  formula  must  be  added  to  in- 
crease the  protein  content  of  the  diet. 


208  INFANT   FEEDING. 

(&)  Buttermilk  or  skim  milk  mixtures  (contain- 
ing two  carbohydrates,  i.e.,  sugar  and 
flour).  The  action  of  both  is  the  same. 
Occasionally  it  is  necessary  in  young  in- 
fants to  reduce  the  sugar  recommended  in 
the  original  formula  (see  Buttermilk  Mix- 
ture, p.  436). 

(c*)  Brady's  buttermilk  mixture  No.  1  (p.  436). 
Change  of  the  diet  is  followed  by  better  sleep,  im- 
proved turgor,  skin  becomes  less  pale,  less  variation  in 
temperature.  Stools  change  from  soap  stools  to  ( 1 )  yel- 
low-brown, alkaline  and  fair  consistency,  when  butter- 
milk mixtures  are  fed,  (2)  acid,  softer,  mahogany- 
brown  color  when  malt  soup  is  fed. 

These  results  of  treatment  are  due  to  the  fact  that  the 
tolerance  for  carbohydrates  is  high,  and  protein  toler- 
ance is  little  impaired.  Each  case  should  be  watched  to 
see  if  an  excess  of  carbohydrates  is  not  being  given  in 
the  new  diet,  which  is  indicated  by  (a)  restlessness,  (&) 
stopping  of  weight  increase  after  an  early  rise,  (c}  ali- 
mentary fever  (irregular),  (d)  too  frequent  stools.  If 
the  cow's  milk  mixtures  are  not  well  tolerated,  human 
milk  is  indicated. 

The  above  mixtures  should  be  gradually  replaced  by 
ordinary  milk  mixtures  after  two  to  eight  weeks. 

In  infants  over  six  months  of  age  one  of  the  most  con- 
stant and  brilliant  therapeutic  results  follows  the  use 
of  a  limited  amount  of  milk  (boiled  or  citrated)  and  the 
free  administration  of  toast,  zwieback,  rusk,  and  cooked 
cereals  given  in  increasing  quantities  up  to  amounts  that 
will  bring  on  a  steady  gain  of  6  to  8  ounces  a  week.  To 
this  diet  broth  or  vegetable  soup  and  orange  juice  should 
be  added  soon.  In  other  words,  if  a  baby  of  six  or  seven 
months  does  not  gain  on  ordinary  milk  mixtures,  it  should 
be  fed  like  a  normal  baby  of  nine  or  ten  months,  with 
the  single  exception  that  the  milk  should  be  kept  rather 
low,  or  at  least  given  cautiously,  and  preferably  boiled 


DISTURBANCES  WITHOUT  DIARRHEA.         209 

or  citrated,  or  both.     In  many  cases  this  can  be  done 
even  in  the  fifth  month. 

Underfeeding  with  Cow's  Milk  Mixtures  of 
Correct  Composition. 

The  cases  of  this  class  include  those  infants  receiv- 
ing a  diet  containing  a  proper  proportion  of  the  neces- 
sary food  ingredients,  however,  in  insufficient  quantity. 
(Too  little  of  a  proper  food.)  These  must  again  be 
divided  into  two  groups: 

(a)  Normal  Infants  Quantitatively  Underfed.  In 
breast-fed  infants  this  group  is  more  common  than  in 
artificially  fed.  And  while  in  the  artificially  fed  such 
cases  are  occasionally  seen,  this  is  a  far  less  frequent 
condition  than  overfeeding.  Because  in  the  normal  in- 
fant hunger  is  manifested  by  crying,  restlessness,  loss 
of  weight  and  associated  constipation,  which  fortunately 
in  most  instances  leads  to  a  proper  interpretation,  result- 
ing in  increase  of  the  diet. 

(6)  Infants  Suffering  from  Nutritional  Disturbances, 
Quantitatively  Underfed.  These  cases  are  the  ones 
which  so  frequently  suffer  from  quantitative  inanition, 
due  to  the  fact  that  the  fever,  vomiting  and  diarrhea 
offer  every  indication  for  a  reduction  in  diet,  or  a  starva- 
tion diet.  While  this  leads  to  an  improvement  in  the 
general  symptoms,  the  remaining  hunger  stool,  because 
of  its  greenish-brown  color  and  excess  of  mucus,  is  not 
uncommonly  interpreted  as  a  diarrheal  stool,  leading  to 
prolonged  starvation  and  not  infrequently  repeated 
catharsis. 

The  result  of  repeated  starvation  must  necessarily  be 
a  condition  of  malnutrition,  which  sooner  or  later  will 
result  in  the  stage  of  athrepsia  (marasmus),  unless  the 
underlying  condition  is  corrected,  and  a  proper  diet 
instituted. 

Treatment.  Repeated  hunger  days  and  long-con- 
tinued underfeeding  should  be  instituted  only  upon  defi- 

14 


210  INFANT   FEEDING. 

nite  indications,  the  sudden  decrease  in  the  food  leading 
regularly  to  weight  loss  and  lowered  food  tolerance. 

An  initial  cathartic  is  frequently  indicated,  while  re- 
peated catharsis  is  harmful. 

The  diet  should  be  as  rapidly  increased  as  the  infant's 
condition  will  tolerate.  It  should  be  carefully  selected 
to  meet  the  requirements  of  the  individual  infant. 

While  in  mild  cases  a  properly  selected  diet  leads  to 
rapid  recovery  and  gain  in  weight,  in  the  severe  cases 
we  not  infrequently  see  a  paradoxical  reaction  to  food, 
necessitating  feeding  as  described  under  the  chapter  on 
Athrepsia. 

In  every  case  the  infant's  tolerance  to  food  should  be 
carefully  studied,  and  increases  made  only  as  tolerance 
permits. 

Hunger  stools  are  rapidly  replaced  by  those  of  normal 
consistency  in  the  presence  of  a  proper  diet. 

Underfeeding  with  Diets  of  Incorrect 
Composition. 

(a)  Diets  with  Insufficient  Cow's  Milk  and  Suf- 
ficient or  An  Excess  of  Sugars.  This  class  of  cases 
are  most  frequently  seen  in  infants  fed  on  proprietary 
foods,  more  especially  condensed  milk  and  the  so-called 
"baby  foods"  composed  largely  of  carbohydrates  to  which 
some  milk  is  added. 

The  tendency  on  the  part  of  the  infant  so  fed  is  to 
store  large  amounts  of  fat.  They  usually  appear  plump, 
but  have  a  tendency  to  develop  secondary  anemia,  rickets 
and  scurvy.  Frequently  diarrhea  will  be  superimposed 
in  the  presence  of  slight  irritation  of  the  gastro-intestinal 
tract  following  mechanical  or  bacterial  causes. 

Infants  fed  upon  such  one-sided  diets  have  a  lessened 
immunity,  both  to  systemic  and  intestinal  bacterial  in- 
fections. They  are  therefore  liable  to  recurrent  infec- 
tions. 


DISTURBANCES  WITHOUT  DIARRHEA.         211 

Treatment.  The  chief  object  should  be  to  place  them 
upon  a  well-balanced  milk  mixture  suitable  to  their  age, 
to  which  well-cooked  cereals  and'  vegetables  are  to  be 
added  as  the  age  permits. 

In  changing  to  cow's  milk  mixtures  from  these  high 
carbohydrate  diets,  it  is  best  to  start  with  small  amounts 
of  milk  first,  adding  one  ounce  of  cow's  milk  for  each 
pound  of  body  weight.  This  is  to  be  increased  as  the 
infant's  condition  permits.  The  carbohydrates  should 
be  reduced  to  amounts  approximating  one-tenth  ounce 
per  each  pound  of  body  weight,  in  addition  to  that  con- 
tained in  the  milk.  Only  in  the  presence  of  severe  diar- 
rhea should  sugars  be  entirely  withdrawn  and  then  with 
caution,  because  of  the  danger  of  collapse.  It  is  advis- 
able to  boil  the  mixture,  at  least  early  in  the  new  feeding, 
in  order  to  split  the  casein  curds.  The  semisolids  should 
be  added  gradually  and  increased  as  indicated  after  the 
infant  has  shown  its  ability  to  first  handle  the  milk 
mixture. 

(b)  Diets  Composed  Chiefly  or  Entirely  of  Starches. 
Synonyms:  Flour  injury,  starch  injury,  mehlnahrschaden 
(Czerny-Keller). 

Etiology.  The  condition  follows  feeding  with  a  diet 
composed  largely  of  cereals  or  cereal  waters,  as  is  fre- 
quently seen  when  these  are  used  to  replace  milk  mix- 
tures which  have  been  poorly  digested  (diarrhea,  etc.). 
It  is  therefore  due  to  continued  feeding  of  flour  gruels, 
either  without  milk  or  a  diet  too  low  in  milk  content. 
Whether  simple  flour  or  baby  foods,  dextrinized  or  not 
are  used,  the  result  is  the  same.  Although  the  flour  in 
its  digestion  is  changed  to  sugar,  the  effects  are  not  those 
of  excessive  sugar  diet  (acute),  but  only  lead  to  acute 
symptoms  after  the  organism  has  been  generally  im- 
paired by  the  long  use  of  the  one-sided  diet. 

Pathogenesis  and  Metabolism.  The  disturbance  of 
the  organism  which  develops  on  one-sided  flour  feeding 
is  to  be  regarded  as  qualitative  inanition,  being  due  to 


212  INFANT   FEEDING. 

the  lack  of  important  tissue-building  substances  (fat, 
proteins,  salts  and  vitamines),  and  the  resulting  improper 
formation  of  the  body  tissues. 

Steinitz  and  Weigert  found  in  animals  that  a  flour  diet 
led  to  an  abnormal  chemical  composition  of  the  organ- 
ism. The  body  became  richer  in  water  and  fat  than  nor- 
mal. The  edema  indicates  a  disturbance  in  the  salt 
balance.  Marriott  believes  that  lack  of  fat-soluble  vita- 
mines  is  an  important  etiological  factor. 

In  many  cases,  also,  the  caloric  intake  may  be  insuffi- 
cient, so  that  quantitative  inanition  complicates  the  pic- 
ture. The  accumulation  of  large  quantities  of  water 
which  occurs  when  large  quantities  of  flour  are  fed  in 
presence  of  salts  results  in  fluctuations  in  weight. 

Rapidity  of  development  depends  on  the  following 
factors : 

1.  Age.    The  younger  the  child,  the  quicker  the  effects 

2.  The  more  the  flour  outweighs  the  other  ingredients 
of  the  diet. 

Symptoms.  They  may  assume  any  form  of  nutri- 
tional disturbance.  In  many  cases  apparent  symptoms 
of  disease  are  lacking  for  a  long  time  in  spite  of  the 
improper  diet.  The  infant  may  even  apparently  thrive 
well,  since  (due  to  the  great  water-binding  property  of 
carbohydrates)  considerable  gains  in  weight  may  occur. 
The  appearance  of  the  child  is  good,  and  fat  cushion 
abundant.  Even  at  this  time,  however,  frequently  some 
anomalies  are  observed :  the  musculature  may  be  slightly 
hypertonic,  the  appearance  may  be  pasty,  suggesting  a 
water-soaked  sponge.  Not  infrequently  by  careful  exam- 
ination nervous  irritability  (latent  tetany)  may  be  de- 
tected. This  is  followed  by  development  of  grave  symp- 
toms of  typical  flour  injury,  which  may  assume  variable 
appearance,  according  to  whether  the  flour  is  given  alone 
or  combined  with  some  other  food. 

Flour  has  the  property  of  causing  the  body  to  take  on 
weight  by  water  absorption.  This  is  especially  true  if 


DISTURBANCES  WITHOUT  DIARRHEA.        213 

the  infant  was  previously  healthy,  and  may  be  mislead- 
ing. In  infants  suffering  from  nutritional  disturbances 
the  picture  develops  more  rapidly,  especially  upon  in- 
auguration of  repeated  starvation  diet.  Finally,  how- 
ever, both  these  groups  of  infants  present  the  picture  of 
an  inanition — that  is,  the  atrophic  stadium,  which  cannot 
be  distinguished  from  a  decomposition  clinically.  They 
are  subject  to  rapid  weight  and  water  losses,  showing  the 
loose  binding  of  the  water  in  the  tissues. 

Edema  may  complicate  the  picture,  especially  where 
the  flour  is  given  in  a  salt-rich  diet  as  bouillon,  milk,  etc., 
and  the  edema  may  resemble  that  of  a  nephritic  patient 
(urine  is  usually  negative). 

The  natural  immunity  in  these  hydremic  conditions  is 
greatly  reduced,  and  the  children  are  subject  to  furun- 
culosis,  otitis,  and  infections  of  the  respiratory  and  diges- 
tive tracts,  all  of  which  give  a  bad  prognosis. 

Hypertonia  is  very  common,  with  a  characteristic  mus- 
cular rigidity,  resulting  in  stiffening  of  extremities,  opis- 
thotonos,  etc.,  and  it  is  often  difficult  to  differentiate 
them  from  cases  of  spastic  cerebral  paralysis  and  chronic 
tetany,  from  which  latter  these  infants  often  suffer. 
The  history  of  nerve  irritability  must  be  used  as  a  point 
of  differentiation. 

Hypertonic  form  has  also  been  described,  the  chief 
symptom  of  which  is  the  rigidity  of  the  muscles.  This 
hypertonicity  may  occasionally  assume  such  proportions 
that  the  limbs  and  the  entire  body  may  become  rigid. 
But  this  condition  is  not  exclusively  caused  by  flour  in- 
jury, but  may  be  seen  also  in  other  nutritional  dis- 
turbances. 

Stools.  Often  the  stools  are  good  for  a  long  time, 
but  sooner  or  later  in  all  cases  acute  intestinal  symptoms 
develop.  More  characteristic,  after  continued  feeding  on 
a  one-sided  flour  diet  are  soft,  mushy,  loose  stools,  which 
are  frequent,  and  vary  in  color  from  brown  to  yellow.  A 
further -characteristic  is  a  tendency  to  fermentation,  with 


214  INFANT   FEEDING. 

the  formation  of  acids  and  gas,  which  tend  to  irritate  the 
buttocks.  The  small,  dark-brown  stools,  composed 
mainly  of  mucus  (hunger  stools),  are  not  infrequently 
seen,  and  are  of  especial  significance,  because  they  are 
often  misinterpreted  as  dyspeptic  stools. 

Diagnosis.  The  feeding  history  is  of  the  utmost 
importance.  Hypertonia  and  edema  should  lead  to  sus- 
picion, as  should  the  presence  of  excessive  fermenta- 
tion and  "hunger  stools." 

Prognosis.  The  younger  the  infant  and  the  longer 
the  unsuitable  diet  has  been  continued,  the  worse  is  the 
prognosis.  The  high  mortality  in  this  condition  is  due 
not  so  much  to  the  nutritional  disturbance  itself,  but 
more  so  to  unavoidably  complicating  infections.  Tetanies 
and  convulsions  due  to  them  are  also  grave  complications. 

Prophylaxis.  The  development  of  a  primary  flour 
injury  is  prevented  by  ordering  proper  diet.  In  using  the 
flour  diet  for  therapeutic  purposes  in  the  treatment  of 
dyspepsia,  especially  when  repeated  starvation  is  in- 
augurated, the  danger  of  development  of  the  flour  injury 
must  be  kept  in  mind,  and  the  one-sided  diet  must  not 
be  continued  longer  than  several  days. 

Treatment.  1.  Human  Milk.  In  young  infants  and 
also  in  all  severe  cases,  feeding  with  human  milk  offers 
the  best  hope  for  the  cure  of  the  condition.  It  is  abso- 
lutely indicated  (1)  before  the  third  month,  (2)  in  evi- 
dence of  decomposition. 

Begin  with  200  to  300  mils  daily,  as  in  decomposition, 
and  continue,  even  with  weight  loss  and  development  of 
dyspeptic  symptoms.  Increase  the  amount  steadily. 
Even  with  human  milk  the  course  will  be  slow,  if  the 
condition  is  well  advanced. 

2.  Artificial  Feeding.  One-half  boiled  skim  or  whole 
milk  plus  water  in  feedings  of  10  times  30  mils  with  water 
or  tea  ad  libitum.  Continue  feeding,  gradually  increasing, 
unless  the  stools  are  dyspeptic.  It  is  of  advantage  to 
hasten  convalescence  by  addition  of  some  sugar  or  mal-' 


DISTURBANCES  WITHOUT  DIARRHEA.         215 

tose-dextrin  preparations  to  the  milk  mixture.  Albumin 
milk  and  buttermilk  mixtures  are  often  taken  to  better 
advantage  than  whole  milk  mixtures.  If  they  fail,  hu- 
man milk  must  be  given.  Codliver  oil  and  orange  juice 
should  be  started  early  in  treatment. 

If  stools  retain  fat-soap  character  after  10  to  14  days, 
the  diet  may  be  more  rapidly  increased. 

Course  is  often  interrupted  by  weight  drops  and  in- 
fections. 

In  very  severe  cases  in  which  symptoms  of  athrepsia 
are  present,  same  treatment  as  in  athrepsia  should  be 
instituted. 

(c)  Diets  Low  in  Vitamines.  It  is  a  well-known  fact 
that  even  in  the  presence  of  diets  containing  proper 
amounts  of  fats,  proteins,  carbohydrates,  mineral  salts 
and  water,  retardation  in  the  development  and  growth 
of  the  body  may  occur.  This  is  frequently  due  to  the 
lack  of  unidentified  substances  which  are  essential  to 
life  and  which  are  described,  for  want  of  a  better  term, 
as  vitamines.  (See  page  18.) 

Beriberi,  pellagra,  scurvy  and  rickets  may  be  wholly 
or  partially  dependent  upon  a  lack  of  vitamines  for  their 
development.  The  so-called  flour  injury  is  also,  in 
part  at  least,  due  to  a  lack  of  vitamines. 

More  recently  it  has  been  shown  that  many  infants 
suffering  from  malnutrition  and  marasmus  show  a 
marked  and  rapid  improvement  in  their  general  condi- 
tion when  foods  rich  in  vitamines,  more  especially  water- 
soluble  B  and  C,  are  added  to  their  diets  in  increased 
amounts. 

Beriberi  has  positively  been  identified  as  a  disease  due 
to  an  insufficiency  in  water-soluble  B  vitamine. 

Pellagra  is  in  all  probability  a  deficiency  disease,  al- 
though there  is  still  considerable  question,  as  to  whether 
other  factors  may  not  be  contributing. 

Scurvy,  judging  from  its  prompt  response  to  treatment 
with  the  water-soluble  C  vitamine,  is  undoubtedly  a  de- 


216  INFANT   FEEDING. 

ficiency  disease,  even  though  in  many  instances  it  does 
not  become  clinically  evident  until  precipitated  by  sec- 
ondary factors,  such  as  an  infection.  (See  page  359.) 

Rickets.  The  pathological  changes  in  the  osseous  and 
muscular  system  are  undoubtedly  due  to  the  inability  to 
utilize  calcium,  with  a  resulting  diminished  retention^  of 
this  element,  notwithstanding  the  fact  that  there  may  be 
a  sufficient  amount  in  the  food  intake  and  in  thejjlood. 
Phosphorus  probably  plays  an  intermediate  role  in  in- 
fluencing the  deposition  of  lime  salts.  It  is  quite  prob- 
able that  a  fat-soluble  vitamine  is  a  factor  in  determin- 
ing the  level  of  the  blood  phosphate  and  thereby  directly 
|  influences  calcium  retention. 

Subacute  and  chronic  infections,  more  especially  of 
the  respiratory  tract,  are  seemingly  influenced  by  ad- 
ministration of  cod-liver  oil,  which  is  high  in  fat-soluble 
vitamine  and  which  leads  to  the  deduction  that  it  has 
.a  more  or  less  direct  influence  in  raising__the_iiiimunity 
,  j:hrough  some  unknown  factor. 

Treatment.  The  administration  of  diets  properly 
constituted  for  the  treatment  of  rickets  is  discussed  on 
page  331  and  scurvy  on  page  379. 

In  the  presence  of  retarded  growth  fat-soluble  A  vi- 
tamine is  best  administered  in  the  form  of  cod-liver  oil, 
and  water-soluble  B  and  C  vitamines,  as  contained  in 
fresh  fruit  juices,  more  especially  in  oranges,  and  fresh 
vegetables,  more  particularly  the  green-leaf  variety,  are 
indicated.1  2  The  infant's  age  permitting,  orange  juice 
should  be  administered  in  amounts  equal  to  one  to  two 
ounces  daily.3  In  a  considerable  number  of  this  type  of 
cases  we  have  found  the  administration  of  one-half  to 
one  cake  of  fresh  yeast  daily  of  great  value.  It  may 
be  given  in  the  orange  juice  or  made  into  a  paste  with 


i  Karr,  W.  G.:  Jour.  Biol.  Chem.,  44,  255,  1920;  44,  277,  1920. 
2Osborne,  J.  B.:  Medical  Record,  97,  630,  1920. 
3  Byfield,  A.  E.:  Daniels,  A.  L.,  and  Loughlin.  R.:  Am.  Tour. 
Dis.  Children  19,  349,  1920. 


DISTURBANCES  WITHOUT  DIARRHEA.         217 

butter  or  mixed  with  the  fruit  pulps,  such  as  prunes  or 
bananas.  The  paste  may  be  spread  on  bread  or  crackers. 
\Yhen  given  in  this  way  there  is  usually  little  objection 
to  taste  on  the  part  of  the  infants.  The  same  line  of 
treatment  is  effective  during  the  convalescence  from 
acute  infections  and  other  debilitating  diseases,  and  in 
the  course  of  chronic  infections. 


CHAPTER  IV. 

NUTRITIONAL  DISTURBANCES  CHARAC- 
TERIZED BY  DIARRHEA. 
(Diarrheal  Disturbances.) 

THE  following  conditions,  characterized  by  diarrhea 
as  the  most  prominent  symptom,  are  described  in  the 
literature:  Acute  intestinal  indigestion,  fermentative 
diarrhea,  infectious  diarrhea,  dyspepsia,  stadium  dyspep- 
ticum,  sugar  indigestion  (zuckernaehrschaden),  fat  in- 
digestion (fettnaehrschaden),  gastro-enteritis,  summer 
complaint,  cholera  infantum,  follicular-enteritis,  mem- 
braneous-colitis. 

Etiology.  Diarrhea  may  develop  either  primarily 
in  a  healthy  infant  or  a  sequel  to  preceding  nutritional 
disturbances  or  it  may  be  secondary  to  an  infection. 

Diarrhea  occurs  as  a  symptom  of  many  conditions  of 
different  etiology.  Usually  it  is  unassociated  with  demon- 
strable pathological  lesions  of  the  intestinal  tract,  and 
unfortunately  these  are  the  types  most  frequently  seen. 
Anatomical  lesions  in  the  intestine,  more  especially  in 
the  lower  ileum  and  large  intestine,  are  constant  find- 
ings in  some  of  the  infectious  types  and  may  be  present 
in  the  subacute  and  chronic  diarrheas,  non-infectious  in 
origin. 

The   most   important   factors   may  be  enumerated   as 
follows : 
1.  Overfeeding  With: 

(a)  Milk  mixture  of  correct  composition  (too  fre- 

quent or  too  much). 

(b)  Milk  mixture  of  incorrect  composition  (excess 

of  fat,  sugar  or  salt). 

(c)  Raw  milk,  with  resulting  mechanical  irritation 

due  to  large,  hard  protein  curds. 
(218) 


DISTURBANCES  WITH  DIARRHEA.  219 

2.  Feeding  with  Spoiled  Milk   (decomposition  products 

of  milk  and  bacterial  toxins). 

3.  Subnormal  Food  Tolerance  Due  to: 

(a)  Preceding  dietetic   errors  and  nutritional   dis- 

turbances. 

(b)  Extremes  of  temperature,  heat  of  summer  and 

cold  of  winter,  with  resulting  systemic  de- 
pression. 

(c)  Constitutional  anomalies: 

1.  Idiosyncrasy  to  cow's  milk. 

2.  Exudative  diathesis  (eczema). 

3.  Neuropathic  diathesis. 

4.  Organic   diseases  of   the   heart,   kidneys, 

liver  and  pancreas. 

4.  Infections: 

1.  Enteral. 

2.  Parenteral. 

5.  Cathartics  (excessive  and  repeated  administration). 
Very  frequently  several  causes  are  combined  in  a  sin- 
gle case,  and  it  often  becomes  impossible  to  make  an 
exact  etiological  diagnosis.     In  all  varieties  of  diarrhea 
there  are  functional  disturbances,  and  in  the  severe  forms 
organic  changes  may  be  present,  or  the  latter  may  de- 
velop in  the  course  of  an  uncorrected  case  which  at  first 
was  only  functional  in  nature.     An  insufficiency  of  the 
intestines  may  soon  be  reached,  which  makes  it  impos- 
sible to  avoid  the  development  of  pathological  fermenta- 
tion  and    leads   to   an    interference    with   absorption   of 
water  and  the  products  of  digestion,  with  the  early  de- 
velopment   of    systemic    derangement.      The    abnormal 
products  of  fermentation  cause  increased  peristalsis  and 
result    in   an   aggravation   of   the    condition   unless   cor- 
rected.    Interference  with  the  normal  function  of  secre- 
tion leads  to  changed  bacterial  content  in  the  intestines. 
It  is,  therefore,  often  impossible  to  determine  whether 
this  changed  bacterial  flora,   as  evidenced  in  the   feces, 
is  the  cause  or  result  of  the  condition. 


220  INFANT   FEEDING. 

Pathogenesis.  The  development  of  this  group  of 
disturbances  will  vary  directly  with  the  underlying  causa- 
tive factor  or  combination  of  causes. 

Those  Due  to  Overfeeding:  With  Milk  Mixtures  of 
Correct  Composition.  In  this  group  vomiting  and  evi- 
dences of  gastric  and  intestinal  indigestion  usually  pre- 
cede the  appearance  of  diarrhea.  In  fact,  many  of  the 
cases  are  unassociated  with  diarrhea,  the  infant  present- 
ing sufficient  evidence  of  distress  to  call  for  reduction 
in  diet  before  the  latter  stage  is  reached.  The  symptoms 
may  be  due  to  incomplete  emptying  of  the  stomach  be- 
tween feedings  when  the  intervals  between  meals  are 
too  short,  or  they  may  follow  overfeeding  when  too 
large  or  too  concentrated  a  diet  is  fed.  Sooner  or  later 
intestinal  symptoms  will  develop  unless  the  dietetic  error 
is  corrected,  due  to  bacterial  action  on  unabsorbed  food 
in  the  intestinal  tract. 

In  the  second  group  due  to  overfeeding  with  milk 
mixtures  of  incorrect  composition,  any  one  or  a  com- 
bination of  the  food  elements  when  in  excess  may  pre- 
cipitate a  diarrheal  disturbance.  By  far  the  largest  num- 
ber of  cases  as  seen  in  practice  fall  within  the  limits  of 
this  group  and  we  will  discuss  it  more  in  detail  because 
of  the  frequency  with  which  it  is  met.  The  protein  is 
not  a  good  culture  medium  for  the  organisms  commonly 
associated  with  the  diarrheal  diseases  and,  therefore, 
when  fed  in  boiled  mixtures,  is  not  a  common  causative 
factor.  On  the  contary,  when  casein  is  fed  in  sufficient 
amounts,  in  boiled,  whole  or  skim  milk  or  in  dry  forms, 
it  counteracts  pathological  fermentation  in  the  intestinal 
tract  and  the  casein  has  a  direct  curative  influence, 
as  seen  .in  the  tendency  to  the  formation  of  alkaline 
stools;  on  the  other  hand,  when  large  quantities  of 
raw  milk  are  fed  there  is  a  tendency  toward  the 
formation  of  so-called  hard  protein  curds  which  may  act 
as  mechanical  irritants  to  the  intestine,  increasing  peri- 
stalsis and  secretion,  with  a  resulting  increase  in  number 


DISTURBANCES  WITH  DIARRHEA.  221 

of  stools  with  a  lessened  consistency.  This  is  rarely 
seen  in  the  normal  infant,  unless  more  than  one  and 
one-half  ounces  of  raw  milk  are  fed  per  pound  body 
weight.  It  may,  however,  develop  on  lesser  quantities 
in  infants  who  have  suffered  from  previous  nutritional 
disturbances.  Far  more  frequent  are  the  cases  brought 
about  by  increased  acid  fermentation,  which  causes  in- 
creased peristalsis  and  increased  intestinal  secretion  with 
resulting  loss  of  body  fluids.  Pathological  breaking 
down  of  carbohydrates  (sugar,  flour)  is  the  most  fre- 
quent cause,  and  is  often  the  primary  factor,  while  the 
fat,  in  most  cases,  is  involved  only  secondarily  as  a  re- 
sult of  increased  peristalsis  and  fermentation.  The 
sugars  in  strong  solution  have  a  hydragogue  action  and 
they  also  provide  a  favorable  medium  for  bacterial 
growth.  While  the  fats  may  have  a  mechanical  effect 
and  thereby  act  as  laxatives,  when  fed  in  excessive 
amounts  this  is  only  exceptionally  the  manner  in  which 
they  cause  diarrhea.  Much  more  frequently,  the  irrita- 
tion is  due  to  the  esters  of  the  lower  fatty  acids  which 
give  rise  to  acids  capable  of  increasing  peristalsis  when 
they  are  split  by  the  enzymes  of  the  digestive  juices. 
This  action  is  enhanced  by  an  excessive  carbohydrate 
fermentation.  It  is  also  true  that  an  excess  of  fat  has 
an  unfavorable  influence  on  the  sugar  tolerance.  By 
the  reduction  or  complete  withdrawal  of  carbohydrates 
the  pathological  fermentation  can  in  almost  all  cases  be 
decreased  and  also  the  peristalsis.  The  different  carbo- 
hydrates show  different  tendency  to  fermentation.  Milk- 
sugar  ferments  most  easily,  less  easily  the  cane-sugar, 
and  least  the  maltose-dextrin  preparations.  By  clini- 
cal experiments  it  was  found  that  the  tolerance  of  even 
the  same  intestine  towards  carbohydrates  is  not  always 
the  same,  and  that  it  also  depends  to  a  certain  extent 
upon  the  quality  of  the  fluid  in  which  they  are  dissolved 
or  suspended.  The  same  amount  of  sugar  given  with 
large  quantities  of  whey  produces  dyspeptic  symptoms 


222  INFANT   FEEDING. 

much  more  easily  than  the  same  amount  of  sugar  ad- 
ministered in  less  whey  or  in  water.  From  this  it  fol- 
lows that  in  pathogenesis  of  this  group  of  artificially  fed 
infants  the  whey  is  also  of  importance,  the  quality  and 
quantity  of  the  whey  salts  may  become  the  deciding  fac- 
tor in  the  development  of  diarrhea.  This  group  of  cases 
is  frequently  described  under  the  title  of  fermentative 
diarrheas.  The  mechanical  diarrhea  due  to  raw  protein 
curds  has  been  described — in  older  infants  similar  cases 
may  be  seen  when  the  semi-<solid  foods  are  given,  more 
particularly  fruits  and  vegetables,  among  the  latter  those 
in  which  the  vegetables  are  not  properly  pureed.  Cer- 
tain vegetables  may  also  act  as  chemical  causes,  more 
commonly  unripe  fruit  and  green  vegetables,  such  as 
apples,  cabbage,  cucumbers,  etc. 

•  Infected  foods,  such  as  spoiled  milk,  may  result  in 
acute  disturbances  which  may  be  due  to  the  bacteria 
themselves  but  more  commonly  to  the  bacterial  action 
on  the  fats  and  sugars  with  the  formation  of  toxic  bodies. 
One  of  the  greatest  disadvantages  of  feeding  infants  on 
commercially  pasteurized  milk,  as  is  done  in  many  of 
the  large  cities,  is  the  fact  that  the  non-pathogenic  lactic 
acid  organisms  are  destroyed  and  many  of  the  patho- 
genic organisms  remain  which  grow  in  the  milk  as  it 
ages.  Therefore,  sweet  milk  does  not  necessarily  mean 
good  milk.  The  destruction  of  the  lactic  acid  organisms 
prevents  the  souring  of  the  milk  which  is  of  best  aid  in 
detecting  stale  milk.  It  is  well  known  that  milk  may 
be  sour  and  cause  no  symptoms.  The  action  of  such  or- 
ganisms as  the  Bacillus  lactis  and  Streptococcus  lactis, 
by  the  production  of  lactic  acid,  exert  an  inhibitory  ef- 
fect'on  many  of  the  pathogenic  organisms,  while  their 
own  products  are  comparatively  harmless. 

Subnormal  food  tolerance  due  to  preceding  dietetic 
errors  and  nutritional  disturbances,  is  one  of  the  most 
important  predisposing  factors  to  recurrent  diarrheal 
disturbances.  Infants  with  such  a  tendency  must  be 


DISTURBANCES  WITH  DIARRHEA.  223 

kept  under  constant  observation  and  the  earliest  evidence 
of  a  tendency  to  the  development  of  a  fresh  attack  must 
be  given  proper  consideration  so  that  the  causative  fac- 
tor may  be  eliminated.  These  are  the  cases  which  so 
frequently  pass  into  the  stage  of  athrepsia  and  anhyd- 
remic  intoxication. 

Infections.  Infants  suffering  from  parenteral  infec- 
tions, such  as  tonsillitis,  rhinitis,  otitis,  pneumonia  and 
pyelitis,  are  likely  to  develop  a  diarrhea  in  the  course 
of  their  infection.  This  is  probably  due  to  the  fact  that 
the  infection  lowers  the  functional  capacity  of  the 
gastro-intestinal  tract,  results  in  lessened  secretion  of 
digestive  juices,  decreased  absorption  and  an  increased 
irritability.  Usually  the  diarrhea  is  preceded  by  fever 
and  often  by  vomiting.  A  careful  study  of  the  diet  re- 
veals no  error  in  the  feeding  and  there  is  usually  a  dis- 
proportion between  the  gastro-intestinal  symptoms  and 
the  evidences  of  systemic  involvement,  more  especially 
the  fever.  While  this  type  calls  for  a  reduction  in  the 
diet,  prolonged  starvation  is  to  be  avoided  in  order  to 
prevent  lessening  of  the  infant's  immunity.  There  is 
another  probable  explanation  for  the  development  of 
diarrhea  in  the  presence  of  parenteral  infection,  in  that 
in  the  presence  of  the  general  debilitating  influence  of 
these  systemic  infections  the  intestinal  mucous  mem- 
brane loses  some  of  its  anti-bacterial  power  and  thus 
allows  bacteria  to  flourish  higher  in  the  intestine  than 
they  would  normally. 

Enteral  infections  will  be  discussed  in  detail  in  a  later 
chapter.  (Page  284.)' 

Extremes  of  temperature,  heat  of  summer  and  cold  of 
winter,  with  resulting  systemic  depression,  lead  to  diges- 
tive disturbances.  It  is  a  well-established  fact  that  in- 
fants are  greatly  depressed  by  overheating  of  the  body 
due  to  high  external  temperatures.  The  condition  is 
readily  aggravated  by  the  wearing  of  excessive  clothing 
during  heat  of  summer;  therefore,  infants  should  be 


224  INFANT   FEEDING. 

dressed  to  meet  the  needs  of  the  temperature  of  a  given 
time  in  the  day.  It  is  wise  to  allow  the  mother  to  use 
her  judgment  as  to  over-  or  underdressing,  after  the 
possible  effect  on  the  child  of  overheating  has  been 
properly  explained.  Most  infants  will  suffer  more  from 
heat  in  the  presence  of  an  excessive  humidity  and  this 
should  also  be  given  proper  consideration  in  considering 
the  clothes  for  the  infant's  use.  It  is  also  true  that  less 
food  is  required  during  the  summer  months  to  nourish 
an  infant,  while  at  the  same  time  more  water  is  needed. 
These  facts  should  be  remembered  and  be  taken  advan- 
tage of  as  prophylactic  and  therapeutic  measures.  Un- 
fortunately, this  is  not  heeded  in  many  cases,  because 
the  child  is  more  thirsty,  and,  its  food  being  liquid, 
quenches  its  thirst  and  is  therefore  given  in  excessive 
amounts;  and  secondly,  because  the  cry  and  discomfort 
due  to  the  same  overfeeding  and  heat  are  interpreted  as 
hunger.  It  should,  therefore,  be  the  duty  of  the  phy- 
sician to  warn  against  excessive  feeding  during  the  hot 
summer  months ;  that  these  latter  are  factors  is  evidenced 
by  the  fact  of  their  prevalence  among  the  poor  and 
ignorant. 

Certain  constitutional  anomalies  lead  to  lessened  food 
tolerance.  Among  these  is  an  idiosyncrasy  to  cow's  milk 
which  is  fortunately  one  of  the  rare  disturbances.  Usu- 
ally the  first  feeding  with  cow's  milk  will  result  in  acute 
vomiting,  diarrhea  and  erythematous  rash  and  not  in- 
frequently low  grade  fever.  Withdrawal  of  cow's  milk 
from  the  diet  usually  results  in  disappearance  of  the 
symptoms.  Infants  suffering  from  the  exudative  di- 
athesis and  infantile  eczemas  often  show  a  tendency 
toward  the  development  of  diarrhea  in  the  presence  of 
minor  dietetic  errors,  more  especially  so  in  the  presence 
of  parenteral  infections,  at  which  time  there  is  a  ten- 
dency on  the  part  of  the  eczema  to  disappear  which  goes 
hand-in-hand  with  the  increased  irritability  on  the  part 
of  the  gastro-intestinal  tract.  Some  infants,  from  birth, 


DISTURBANCES  WITH  DIARRHEA.  225 

show  a  tendency  to  develop  marked  nervous  manifesta- 
tions upon  slight  external  irritation.  It  is  this  class  of 
cases  which  early  develop  pylorospasms  and  repeated 
vomiting.  They  are  also  subject  to  attacks  of  gastro- 
intestinal colic  and  they  are  often  hypersensitive  to  light 
and  sound.  They  form  bad  habits  which  lead  to  im- 
proper feeding  due  to  misinterpretation  of  their  cry. 
Intestinal  disturbances  are  common  complications.  Even 
in  the  ordinary  infant  nervous  exhaustion  and  excitement 
lead  to  impaired  gastro-intestinal  functioning  and  must 
be  avoided. 

Chronic  diseases  of  the  heart  and  kidneys,  more  espe- 
cially when  associated  with  decompensation,  are  fre- 
quently accompanied  by  diarrhea.  These  are  in  large 
part  due  to  interference  with  elimination.  Chronic  dis- 
turbances of  the  liver  and  pancreas  may  be  underlying 
factors  in  the  development  of  diarrhea. 

Repeated  and  excessive  administration  of  cathartics 
is  one  of  the  most  common  causes  of  diarrhea.  It  has 
been  conclusively  shown  that  the  stools  become  abnor- 
mal in  the  presence  of  repeated  cathartics.  Calomel, 
when  given  in  divided  doses  of  one-tenth  grain  per  dose, 
with  a  total  administration  of  one  grain  daily  for  three 
consecutive  days,  will  cause  the  presence  of  mucus  and 
.  blood  in  practically  every  case ;  one  dram  of  magnesium 
sulphate,  given  daily  for  three  days,  will  cause  the  same 
result;  castor  oil,  while  less  irritating,  when  repeated, 
will  cause  a  similar  reaction.  It  is  self-evident  that  re- 
peated catharsis  is  to  be  avoided. 

Symptoms.  Acute  intestinal  indigestion  is  charac- 
terized clinically  by  acute  gastro-intestinal  symptoms, 
the  most  marked  of  which  are  the  stools,  which  are  in- 
creased in  number,  and  of  an  abnormal  quality.  In  the 
milder  types  the  organism  does  not  show  signs  of  any 
deep-seated  general  changes  and  weight  loss  is  moderate. 
Quite  commonly  the  gastric  disturbances  are  associated 
with  diarrhea,  the  causative  influence  being  something 

15 


226  INFANT   FEEDING. 

ingested  which  irritates  the  stomach  and  then  passes  into 
the  bowels,  or  both  may  be  affected  simultaneously  in 
the  presence  of  systemic  involvement.  Temperature  is 
moderately  increased,  and  repair  is  rapid  with  the  with- 
drawal of  improper  food.  The  presence  of  high  or  con- 
tinued fever  should  lead  to  a  careful  search  for  a  sys- 
temic involvement  outside  of  the  gastro-intestinal  tract 
and  for  evidence  of  an  indefinite  infection. 

Severe  general  symptoms  are  usually  absent  in  the 
early  stages.  The  mind  is  clear.  The  heart  action  is 
not  rapid.  Respirations  are  not  greatly  increased.  The 
baby  is  restless  and  fretful,  cries  a  great  deal  of  the  time, 
sleeps  brokenly,  and  sucks  its  hands  and  other  objects 
as  if  hungry.  The  face  soon  becomes  drawn,  and  the 
tissues  more  or  less  flabby  through  loss  of  body  fluids. 
The  skin  shows  little  change.  The  urine  is  diminished 
in  amount,  the  quantity  being  dependent  upon  the  amount 
ingested,  and  the  extent  of  loss  of  fluids  through  vomit- 
ing and  diarrhea  and  through  loss  by  way  of  the  skin. 
In  the  milder  types  there  are  no  other  abnormal  urinary 
findings. 

Weight.  The  weight  loss  varies  directly  with  the  loss 
of  body  fluids  through  the  increased  secretion,  intestinal 
peristalsis  and  consequent  diarrhea. 

Gastro-intestinal  Symptoms.  The  appetite  is  poor. 
The  mucous  membrane  of  the  mouth  is  red,  and  may 
be  the  seat  of  thrush  (due  to  decreased  immunity). 
Vomiting  may  be  present,  and  usually  occurs  long  after 
feeding,  more  often  preceding  diarrhea  by  from  twelve 
to  twenty-four  hours.  Volatile  fatty  acids  may  be  de- 
tected in  the  stomach  content  by  their  odor.  The  abdo- 
men is  distended,  and  peristalsis  increased,  and  is  visible 
or  can  be  heard  by  auscultation.  Restlessness  is  marked 
and  is  usually  relieved  temporarily  upon  passage  of 
flatus. 

Stools.  The  clinical  diagnosis  is  usually  made  from 
the  stools.  They  are  increased  in  frequency,  and  they 


DISTURBANCES  WITH  DIARRHEA.  227 

also  differ  from  the  normal.  They  are  thinner,  con- 
tain more  mucus,  and  are  either  watery  or  hashy.  There 
is  an  abnormal  odor,  either,  that  of  decomposition  or 
that  of  acid  fermentation.  The  reaction  is  variable, 
mostly  acid.  The  color  of  the  stool  is  often  green,  this 
being  due  to  transformation  of  bilirubin  to  biliverdin  by 
oxidizing  ferments.  It  is  then  passed  without  being  re- 
duced to  urobilin,  the  normal  transformation  in  the  large 
intestine. 

The  increased  peristalsis  results  in  impairment  of  ab- 
sorption, which  may  easily  be  determined  by  metabolic 
experiments,  and  also  estimated  by  macroscopic,  micro- 
scopic, and  chemical  examination  of  the  stools. 

Fatty  acids  and  calcium  and  magnesium  soaps  appear 
in  the  stools  in  the  shape  of  white  or  yellowish  lumps, 
and,  by  addition  of  strong  acids  and  slight  warming, 
fatty  acid  needles  may  be  crystallized  from  them. 

Part  of  the  fat  is  present  in  the  form  of  smaller  or 
larger  neutral  fat  globules. 

The  acid  reaction  is  in  the  greater  part  due  to  the 
fermentation  of  sugar  which  has  escaped  absorption  in 
the  small  intestine  and  which  is  supplied  by  bacteria  in 
the  colon.  When  considerable  amounts  of  sugar  are 
fermented  in  this  way  the  stools  become  foamy.  The 
irritation  of  the  colon  also  leads  to  excessive  secretion 
of  mucus  and  later  blood  may  appear.  The  appearance 
of  blood  varies  with  the  places  of  hemorrhage  and  the 
time  which  it  is  in  contact  with  the  intestinal  contents. 
The  presence  of  pus  should  lead  to  the  suspicion  that 
ulceration  of  the  intestinal  mucosa  has  taken  place.  The 
latter  is  rarely  present  in  the  simple  types  of  intestinal 
indigestion  and  should  be  considered  as  a  grave  com- 
plication. 

If  flours  are  in  excess,  the  stools  are  frequently  paste- 
like  and  foamy.  By  iodine  solutions  the  unchanged 
starches  are  stained  blue,  and  the  erythrodextrin  is  stained 
red. 


228  INFANT  FEEDING. 

Recent  research  has  demonstrated  the  frequency  with 
which  casein  is  found  in  the  stools.  The  yellowish 
lumps,  the  so-called  milk-curds,  in  the  hashy  stools,  seen 
even  in  feeding  with  boiled  milk,  have  erroneously  been 
regarded  as  casein  curds.  Today  we  know  positively  that 
these  so-called  "casein  curds''  are  composed  chiefly  of 
fatty  acid  salts  and  bacteria.  In  feeding  with  raw  milk 
large,  tough,  bean-like  casein  curds  may  pass  through 
the  intestine  without  being  digested.  Even  in  the  pres- 
ence of  true  casein  curds,  however,  one  must  not  con- 
clude that  they  are  the  primary  factors  in  the  pathogene- 
sis  of  this  nutritional  disturbance  unless  we  are  certain 
that  an  excess  of  raw  milk  has  been  fed. 

Varieties.  First,  the  acute,  which  begins  with  a  defi- 
nite acute  onset,  usually  in  infants  who  have  been  previ- 
ously well,  and  second,  the  chronic,  which  begins  less 
acutely,  or  follows  acute  attacks,  and  which  recurs  even 
in  the  presence  of  a  carefully  regulated  diet.  It  soon 
becomes  evident  that  in  the  latter  cases  there  is  a  definite 
lessening  of  the  food  tolerance. 

Diagnosis.  The  diagnosis  can  be  made  only  by  care- 
ful consideration  of  the  feeding  history  and  the  clinical 
and  functional  symptoms. 

It  is  first  necessary  to  differentiate  those  unassociated 
with  infection  from  the  milder  forms  following  enteral 
and  parenteral  infections.  One  must  remember  that  the 
infections,  especially  in  young  infants,  are  frequently 
associated  with  a  secondary  nutritional  disturbance,  and 
vice  versa,  that  secondary  infections  commonly  follow 
in  the  wake  of  nutritional  disturbances.  An  infection 
should  be  suspected  when  the  temperature  remains  high 
after  the  withdrawal  or  reduction  of  the  food  (especially 
of  the  carbohydrates),  and  when  albumin  and  hyaline 
casts  appear  in  the  urine,  and  the  mucus  continues  in 
excess  in  the  stools,  presenting  the  picture  of  a  second- 
ary enterocolitis  after  the  correction  of  dietetic  errors. 
If  infections  are  not  recognized,  there  is  a  great  danger 


DISTURBANCES  WITH  DIARRHEA.  229 

of  continuing  the  starvation  diet  too  long,  and  thereby 
reducing  the  vitality  of  the  infant  to  the  stage  of  athrep- 
sia.  It  is  also  of  importance  to  note  whether  it  is  a 
primary  or  an  acute  exacerbation  in  the  course  of  an 
athrepsia,  as  on  this  differentiation  to  a  great  extent  de- 
pends the  prognosis  and  the  therapy.  Here,  again,  a 
careful  history  is  of  vast  importance,  and  one  should 
carefully  note  the  presence  of  repeated  attacks,  with  re- 
curring fluctuations  in  weight,  the  occurrence  of  previ- 
ous infection,  both  enteral  and  parenteral,  as  all  of  these 
indicate  a  tendency  to  malnutrition. 

Prognosis.  In'  infants  previously  healthy  and  with 
a  proper  dietetic  treatment,  the  prognosis  is  good.  Re- 
peated attacks  should  always  be  seriously  considered. 
Intestinal  indigestion  in  very  young  infants  is  always 
more  serious  than  in  the  older  and  better  developed  ones. 
The  determination  of  the  stage  of  nutritional  disturbance 
gives  us  no  indication  as  to  whether  we  have  a  light  or 
serious  disturbance.  What  the  physician  needs  to  learn 
is  that  the  condition  of  the  infant  should  not  be  esti- 
mated only  by  its  weight  and  the  character  of  the  stools, 
but  also  on  the  basis  of  its  tonus  and  turgor,  the  color 
of  the  skin  and  the  state  of  the  sensorium.  We  must 
necessarily  consider  the  nature  and  the  quantity  of  the 
stools,  since  the  diagnosis  of  this  condition  is  in  the  first 
place  determined  by  the  presence  of  diarrhea.  The  de- 
gree of  stomach  involvement,  however,  must  be  based 
on  the  condition  of  the  infant  in  whom  it  occurs.  As 
a  rule,  most  cases,  if  promptly  treated,  belong  to  the 
class  of  milder  nutritional  disturbances.  However,  these 
infants  are  always  in  danger  of  developing  a  general 
serious  disturbance,  more  especially  the  very  young  and 
those  who  have  suffered  from  repeated  attacks  as  the 
result  of  long-continued  starvation  and  excessive  loss  of 
water  and  body  fluids,  both  of  which  tend  to  a  destruc- 
tion of  the  tissues.  For  practical  purposes  it  is  well  to 
classify  these  infants,  as  to  prognosis,  into  three  types: 


230  INFANT   FEEDING. 

first,  those  who  have  been  previously  normal;  second, 
those  suffering  from  mild  degrees  of  malnutrition,  and 
third,  those  seriously  emaciated  either  through  consti- 
tutional defects  or  repeated  nutritional  disturbances. 
Among  the  latter  group  those  that  suffer  from  repeated 
diarrheal  attacks  are  especially  likely  to  succumb.  A 
very  acute  nutritional  disturbance  prepares  the  field  for 
the  subsequent  ones  and  decreases  the  tolerance  for  the 
various  food  mixtures.  All  diarrheal  attacks  have  a  ten- 
dency to  result  in  the  stage  of  malnutrition,  and  the  se- 
verer ones  in  marasmus,  which  latter  condition  will  be 
described  in  the  chapter  on  Athrepsia. 

The  loss  of  water  by  way  of  the  stools  and  skin  and 
the  diminished  retention  as  a  result  of  vomiting  tend  to 
a  desiccation  of  the  body  tissues,  which  in  the  severe 
types  leads  to  the  characteristic  clinical  picture  which 
will  be  described  in  the  chapter  on  Anhydremic  Intoxi- 
cation. 

Treatment.  Prophylactic  Measures.  During  the  heat 
of  summer  and  where  there  is  any  uncertainty  as  to  the 
quality  of  the  milk  it  should  be  boiled.  It  should  also 
be  remembered  that  less  food  and  more  water  are  re- 
quired during  the  hot  months.  Over-clothing  in  sum- 
mer and  insufficient  protection  in  winter  predispose  to 
diarrheal  conditions.  In  the  presence  of  diarrhea  high 
carbohydrate  feeding  should  be  discontinued. 

Human  Milk.  The  best  treatment  of  all  forms  of 
intestinal  indigestion  consists  of  feeding  human  milk.  The 
younger  the  infant,  the  more  the  indication  for  human 
milk.  This  is  especially  true  of  infants  under  two  months 
of  age.  In  severe  cases  it  may  be  necessary  to  place  the 
infant  on  a  starvation  diet  for  six  to  twelve  hours,  and 
then  administer  the  breast  milk  in  restricted  amounts. 

Artificial  Feeding.  In  artificial  feeding  the  treatment 
of  acute  intestinal  indigestion  is  somewhat  different  from 
the  treatment  of  the  chronic  variety. 


DISTURBANCES  WITH  DIARRHEA.  231 

Acute  Forms.  In  the  acute  form,  where  the  child  was 
previously  well  and  its  tolerance  good,  the  simple  un- 
loading of  the  intestine  may  allow  it  to  resume  its  nor- 
mal function.  The  following  treatment  is  recommended : 

1.  Starvation  or  Hunger  Diet.     Short   (six  to  twelve 
hours,  rarely  longer)    starvation,  only  liquids  being  ad- 
ministered, tea  with  saccharin  being  the  best  (saccharin, 
1   grain   (0.065  Gm.)   to  1   quart   (1000  mils)).     They 
should  be  given  freely,  up  to  amounts  of  the  total  fluids 
needed.     This  permits  the  stomach  and  the  intestines  to 
empty  themselves,  and  to  assume  their  normal  functions. 
Laxatives    are    usually    not    indicated.       If    temporary 
starvation  is  inaugurated,  the  intestinal  tract  soon  emp- 
ties itself  of  its  irritating  contents. 

Upon  suspicion  that  spoiled  or  otherwise  improper 
food  has  been  fed,  a  single  dose  of  cathartic  may  be  in- 
dicated. Of  these  the  least  harmful  are  castor  oil  and 
milk  of  magnesia.  The  repeated  administration  of  laxa- 
tive drugs  is  absolutely  contraindicated.  This  applies 
more  especially  to  calomel. 

2.  Indifferent  Diet.     During  the  second  day  in  young 
infants,  one-third  whole  or  skim  milk   (boiled  five  min- 
utes) plus  two-thirds  water  or  thin  oatmeal  gruel,  with- 
out sugar,  may  be  fed,  such  a  diet  being  low  in   food 
value  and  salts.     The  total  daily  quantity   of   the  milk 
mixture   on   the   second   day    should   not   exceed    six   to 
eighteen  ounces  (180  to  540  mils),  divided  into  six  feed- 
ings of  one  to  three  ounces  each.     To  this,  twenty  to 
twenty-five  ounces  of  tea,  plus  saccharin,  may  be  added, 
making  a  total  of  at  least  one  quart  of  fluid  for  the  day. 
Even  better  results  will  be  obtained  by  the  use  of  lactic 
acid  milk,  at  first  fat- free  and  later  whole.     These  can 
be  prepared  by  inoculating  boiled  milk  with  a  pure  live 
culture   of  one  of  the   lactic  acid-producing  organisms 
which  can  be  obtained  on  the  market.     The  preparation 
of  the  lactic  acid  milk  can  be  begun  with  the  institution 
of  the  starvation  period,  as  it  must  be  inoculated  from 


232  INFANT  FEEDING. 

twelve  to  twenty-four  hours,  after  which  it  must  be  kept 
on  ice.  The  lactic  acid  milk  can  be  fed  in  somewhat 
larger  amounts  than  sweet  milk.  This  is  probably  due 
to  the  fact  that  the  lactic  acid  bacillus  has  a  retarding 
action  on  the  growth  of  many  of  the  other  organisms 
which  may  be  present  in  the  intestinal  tract.  Such  an 
action  is  especially  valuable  when  it  affects  the  growth 
of  the  abnormal  flora  in  the  upper  intestinal  tract,  know- 
ing that  the  irritation,  more  particularly  of  the  small 
intestine,  interferes  with  the  process  of  digestion  and 
absorption  which  are  so  necessary  to  the  relief  of  this 
class  of  infants.  In  young  infants  and  in  the  severer 
cases  lactic  acid  milk  prepared  from  skim  milk  is  to  be 
recommended  over  that  made  from  whole  milk  during 
the  first  stage  of  the  treatment. 

Further  treatment  depends  on  the  reaction  to  the 
above.  Upon  this  treatment  the  general  condition  im- 
proves, also  the  disposition,  etc.,  and  the  weight  loss 
ceases  in  two  or  three  days.  When  this  is  not  the  case, 
infection  should  be  suspected. 

3.  Sustaining  Diet.     Gradually,  and  as  rapidly  as  pos- 
sible, the  food  should  be  increased,  the  increase  to  be 
made  at  least  every  other  day,  in  order  to  limit  the  under- 
feeding to  a  minimum.     By  the  third  day  or  before,  the 
quantity  of   food  should  be  increased,  the  quality  may 
be  left  unchanged,  giving  water  or  tea  to  the  necessary 
quantity  of  fluids  between  the  feedings.   Weight  increase 
should  not  be  expected  because  of  the  low  sugar  content 
and  low  caloric  value  of  the  diet,  but  a  decrease  in  weight 
should  always  be  considered  serious.     The  stools  are  at 
first  small  and  contain  mucus,  later  less  frequent,  and 
often  on   milk  mixtures  without   sugar   fat-soap   stools 
soon  appear,  which  is  a  good  indication. 

4.  Ordinary  Diet.     In  mild  cases,  the  ordinary  milk 
mixtures  proper  for  the  given  infant  may  usually  be  re- 
sumed by  the  end  of  a  week.     In  more  severe  cases, 
return  to  a  full  diet  should  be  slower.     In  these  mix- 


DISTURBANCES  WITH  DIARRHEA.  233 

tures,  the  carbohydrates  should  be  started  by  adding  one 
gram  and  gradually  increased  to  four  or  five  grams  for 
each  pound  of  body  weight,  only  exceptionally,  however, 
should  the  total  addition  of  sugar  exceed  forty-five 
grams  (I1/-,  ounces).  The  carbohydrates  most  suitable 
for  this  purpose  are  the  maltose-dextrin  compounds,  es- 
pecially those  with  a  high  dextrin  content  and  no  potas- 
sium carbonate.  Corn  syrup  is  also  valuable,  being  in  part 
at  least  absorbed  in  the  upper  intestinal  tract  and  thereby 
causing  less  intestinal  irritation.  It  may  be  added  in 
amounts  of  15  to  60  mils  to  the  day's  total  food.  In  older 
infants  cereals,  in  the  form  of  flour  ball,  barley  flour, 
farina,  zweibach,  can  often  be  added  to  advantage,  as 
well  as  clear  broths.  At  first  there  is  a  rapid  increase  in 
weight,  later  on  a  slower  one. 

Avoid  underfeeding  too  long,  even  if  the  stools  look 
bad,  if  the  temperature  and  weight  curves  improve,  be- 
cause of  the  danger  of  athrepsia.  It  should  be  borne 
in  mind,  therefore,  that  it  is  undesirable  to  underfeed 
for  a  long  period,  and  more  especially  dangerous  to  in- 
augurate starvation  repeatedly,  or  to  keep  an  infant  for 
days  on  a  starvation  diet,  such  as  cereal,  waters  or  very 
weak  milk  mixtures.  It  is  also  necessary  to  know  and 
recognize  the  stools  of  an  underfed  infant  (hunger 
stool).  This  is  greenish-brown  in  color,  composed  chiefly 
of  mucus,  and  small  in  amount,  and  sometimes  frequent. 
They  should  not  be  mistaken  for  the  curd-containing, 
frequent  stools  of  intestinal  indigestion,  as  the  former 
is  an  indication  for  the  resumption  of  food,  while  the 
latter  indicates  starvation.  Fats  can  be  added  in  place 
of  sugars,  but  this  should  be  done  with  care.  Cod-liver 
oil  has  given  us  the  best  results.  It  should  be  given  in 
small  quantities  at  first,  beginning  with  one  mil  twice 
daily,  and  increased  to  four  mils  per  dose. 

In  some  infants  the  above-described  treatment  is  un- 
successful. In  one  group  of  these  cases  the  loss  of 
weight  is  not  favorably  influenced,  while  the  stools  im- 


234  INFANT   FEEDING. 

prove;  and  in  a  second  group  the  loss  continues  with 
continued  diarrhea.  In  these  cases  there  is  either  infec- 
tion or  they  are  cases  of  grave  nutritional  disturbances 
on  transition  to  athrepsia.  It  would  be  a  very  great 
mistake  to  continue  starvation  longer,  with  the  idea  that 
by  giving  the  digestive  tract  longer  rest,  it  may  still  re- 
cover. This  may  kill  the  child.  In  these  cases  treat- 
ment as  recommended  for  athrepsia  or  infection  must 
be  instituted.  Therefore,  it  is  advisable  to  use  routine 
treatment  as  described  above,  and,  if  not  successful,  the 
underfeeding  should  not  be  continued  under  any  cir- 
cumstances, but  the  treatment  for  athrepsia  (described 
later)  or  infection  (see  Infections)  should  at  once  be 
instituted,  if  human  milk  is  not  obtainable. 

It  is  in  these  cases  that  Finkelstein's  albumin  (pro- 
tein) milk  is  indicated.  (See  Appendix,  for  preparation.) 
The  albumin  milk  may  be  administered  undiluted  in  the 
same  quantities  recommended  for  the  lactic  acid  milk 
and  increased  three  ounces  (ninety  mils)  daily  until 
three  ounces  per  pound  (180  mils  per  kilogram)  are 
administered. 

The  value  of  feeding  with  the  lactic  acid  milk  and 
albumin  milk  is  due  to  the  presence  of  the  lactic  acid 
bacillus  and  its  product,  lactic  acid,  and  their  high  pro- 
tein and  low  sugar  content  and  their  small  curd.  The 
latter  also  has  the  added  advantage  of  having  a  low  salt 
content.  After  the  stools  become  firm,  sugar  should  be 
added  to  both  the  lactic  acid  milk  and  the  albumin  milk, 
beginning  with  one-half  to  1  gram  and  gradually  increas- 
ing to  four  grams  for  each  pound  of  body  weight,  with 
a  maximum  addition  of  forty-five  to  sixty  grams.  Car- 
bohydrate starvation,  more  especially  in  the  presence  of 
high  fever,  is  an  added  danger,  and  addition  of  sugar 
to  the  diet  may  be  imperative,  even  in  the  presence  of 
soft  stools.  Maltose-dextrin  compounds  which  do  not 
contain  potassium  carbonate  are  the  best  for  this  pur- 
pose. We  have  found  that  1  per  cent,  of  flour  (flour  ball) 


DISTURBANCES  WITH  DIARRHEA.  235 

may  be  added  to  the  albumin  milk,  thereby  raising  its 
caloric  value  without  decreasing  its  efficacy,  at  the  first 
feeding.  After  three  or  four  weeks,  in  both  mixtures, 
it  is  usually  safe  to  replace  them  in  part  or  entirely  by 
a  suitable  milk  formula  for  a  child  of  a  given  age.  It 
is  usually  wise  to  reduce  the  sugar  in  the  formula  dur- 
ing the  first  days  of  the  new  feeding. 

When  it  is  not  practical  to  prepare  the  lactic  acid  milk 
or  the  albumin  milk  in  the  home,  the  albumin  milk  may 
be  used  in  the  dry  form,  in  which  it  can  be  obtained  on 
the  market  (See  Appendix). 

The  protein  content  of  the  sweet  milk  mixtures  can 
also  be  increased  when  desired  by  the  addition  of  one 
of  the  casein  products  which  are  now  to  be  obtained  in 
quantities  varying  from  1  to  3  per  cent,  of  the  milk  con- 
tent in  the  mixture  (See  Appendix). 

For  the  treatment  of  the  severe  types  with  toxic  symp- 
toms, see  Anhydremia.  The  treatment  of  enteral  infec- 
tions is  discussed  in  the  chapter  on  Infection  and 
Nutrition. 

Chronic  Cases.  In  treatment  of  chronic  forms  there 
is  no  indication  for  underfeeding.  Since  here  there  is 
no  transitory  weakness,  but  a  chronic  weakness  of  toler- 
ance, the  additional  trauma  of  starvation  would  have  an 
unfavorable  influence.  Fats  must  be  reduced.  .  Skim 
milk,  buttermilk  and  albumin  milk  are  often  better  taken 
than  whole  milk  mixtures.  Carbohydrates  are  to  be  re- 
duced to  the  infant's  minimal  needs  (two  to  four  grams 
per  pound  body  weight),  and  the  less  easily  assimilable 
carbohydrates  may  be  replaced  by  those  that  are  more 
easily  assimilated  (maltose-dextrin  mixtures  or  corn 
syrup).  If  this  does  not  improve  the  stools,  then  nurs- 
ing on  the  breast  is  necessary.  The  quantities  of  foods 
taken  should  be  carefully  measured  and  recorded  to 
prevent  prolonged  underfeeding  with  the  hope  that  when 
the  child  becomes  older  the  tolerance  will  become  physio- 


236  INFANT   FEEDING. 

logically  increased,  and  the  condition  thereby  undergo 
spontaneous  healing. 

Medicinal  Treatment  This  is  unnecessary  in  most 
cases.  When  the  starvation-  period  shows  no  tendency 
to  decrease  the  number  of  stools  and  where  there  is  con- 
siderable pain  and  flatulence,  it  may  be  necessary  to 
administer  small  doses  of  opium  and  atropin.  Paregoric 
is  the  safest  form  for  administration  of  opium.  Depend- 
ing upon  the  age,  it  may  be  administered  in  doses  from 
two  to  ten  minims,  to  be  repeated  as  indicated  by  the 
effect  on  the  gastro-intestinal  tract  and  the  general  symp- 
toms. If  atropin  is  used,  the  doses  must  be  carefully 
graduated,  in  young  infants,  and  should  range  from 
Hsoo  to  %00  of  a  grain.  Epinephrin  in  %000  solution, 
1  to  5  minims  by  mouth,  may  be  indicated  where  there 
is  marked  atony  on  the  part  of  the  intestinal  tract.  A 
pure  culture  of  lactic  acid,  when  feeding  sweet  milk  mix- 
tures, is  often  of  value.  It  may  be  administered  in  the 
form  of  powder  or  liquid  culture. 

Marriott  has  recently  recommended  the  administra- 
tion of  argyrol.  He  advises  6  grain  doses  prescribing  it 
in  a  10  per  cent,  solution,  of  which  4  mils  are  given  in 
each  feeding.  It  can  be  continued  for  from  two  days  to 
two  weeks.  He  believes  that  this  has  an  inhibitive  action 
on  the  growth  of  the  bacterial  flora  in  the  upper  intes- 
tinal tract.  The  stools  are  stained  a  deep  brown  when 
such  medication  is  used. 

For  the  treatment  of  irritative  conditions  which  per- 
sist even  after  the  intestinal  indigestion  proper  has  dis- 
appeared (loose  stools  in  presence  of  gain  in  weight), 
astringents  are  of  use.  Tannigen  or  tannalbin,  1  to  5 
grains  (0.065  to  0.325  Gm.)  four  to  five  times  daily, 
will  answer,  or  calcium  lactate  in  doses  of  10  to  15 
grains  (0.65  to  1  Gm.)  may  be  prescribed  in  a  10  per 
cent,  solution  to  be  added  to  each  milk  feeding. 


CHAPTER  V. 
ATHREPSIA  (DECOMPOSITION). 

Synonyms:  Malnutrition,  marasmus,  infantile  atrophy,, 
pedatrophy. 

The  term  athrepsia  was  first  used  by  Parrott  in  1877 
to  describe  secondary  nutritional  disturbance  with  result- 
ing severe  malnutrition.  The  same  symptom-complex 
is  described  as  the  "stage  of  decomposition"  by  Finkel- 


Fig.  9. — Infant  with  athrepsia  (decomposition). 

stein.  The  milder  types  of  athrepsia  are,  in  the  Ameri- 
can literature,  described  as  cases  of  malnutrition  and 
the  more_  extreme  grades  as  marasmus.  The  cases  will 
range  in  severity  from  those  which  simply  show  an  in- 
sufficient gain  or  a  stationary  weight  with  few  systemic 
changes,  to  the  most  extreme  types,  which  will  be  de- 
scribed more  in  detail. 

The  clinical  picture  may  be  viewed  as  the  end-result 
of  repeated^nutritional  disturbances  or  constitutional 
factors.  The  result  of  such  prolonged  or  repeated  under- 
nourishment must  necessarily  be  malnutrition,  of  a  more 
or  less  marked  degree,  depending  upon  the  disproportion 

^between  the  food__utilized  and  the  needs  of  the  body  for  ) 

I  energy  and  growth. 

The  past  history  of  the  patient  is  of  the  utmost  im- 
portance, and  a  careful  search  reveals  improper  diets, 

(237) 


238  INFANT   FEEDING. 

with  resulting  disturbance  of  nutrition,  or  a  nutritional 
disturbance  following  enteral  or  parenteral  infections, 
each  leaving  in  its  wake  evidence  of  impaired  nutrition, 
until  after  weeks  or  months  we  have  reached  the  stage 

/  of  deep-seated  tissue  starvation.  Most  frequently  athrep- 
sia  results  from  repeated  injuries  and  therefore  is  classed 
as  a  subacute  or  chronic  condition.  It  may,  however, 
develop  more  rapidly  in  the  presence  of  an  acute  diar- 
rheal  disturbance.  The  chronic  infections,  such  as 
syphilis  and  tuberculosis,  pyelitis  and  otitis,  may  also  re- 
sult in  a  similar  picture,  but  must  be  differentiated  to 
clear  the  classification  for  therapeutic  purposes.  It  is 
very  commonly  seen  In  infants  suffering  from  congeni- 

1  tal  weakness  or  disease,  such  as  prematurely  born  infants 

/  and  those   suffering   from   congenital   heart,   pulmonary, 

/  gastro-intestinal  and  cerebral  lesions. 

During  this  stage  it  becomes  increasingly  difficult  for 
the  infant  to  assimilate  a  sustaining  diet,  with  resulting 
extreme  loss  of  weight,  and  of  resistance  of  the  organ- 
ism to  infections  and  other  injurious  external  influences 
(heat,  cold),  this  general  weakening  of  the  vitality  of 
the  infant  being  due  to  perverted  metabolism,  consisting 
of  breaking  down  of  the  body  substance,  and  change  in 
the  composition  of  the  cells  (abnormal  katabolism),  and 
of  deficient  and  improper  assimilation  of  the  food  (ab- 
normal anabolism). 

Etiology.  The  milder  types  of  malnutrition  due  to 
dietetic  errors  are  usually  direct  forerunners  of  the  stage 
of  athrepsia.  All  the  factors  which  lead  to  diarrhea  dis- 
turbances, anhydremia  and  intoxication  may  also  be 
causative  factors  of  athrepsia.  At  what  moment  this 
change  takes  place  we  have  no  means  of  telling,  but  we 
know  that  deep-seated  organic -changes  are  necessary  to 
its  development;  these  changes  which  produce  such  an 
intolerance,  toward  nourishment  may  have  developed 
previously  to  the  preceding  illness,  or  during  its  course. 
Premature  infants  are  especially  predisposed,  also  young 


, 


ATHREPSIA.  239 

infants  with  previous  dietetic  errors  and  diarrheal  at- 
tacks, also  those  fed  on  a  one-sided  diet,  excessive  in 
carbohydrates,  especially  cereal  waters  and  gruels,  as 
seen  in  too  long  continued  "starvation  diet."  Especially 
to  the  very  young  does  the  statement  as  to  cereal  waters 
and  gruels  apply.  All  of  the  preceding  reduce  the  toler- 
ance toward  assimilation  of  a  full  and  normal  diet.  The 
tendency  to  athrepsia,  and  therefore  to  the  narrowing 
of  the  nutritional  sphere^  increases  with  each  diarrheal_ 
attack.  Czerny's  internal  hunger,  or,  as  he  commonly 
calls  it,  "cell  hunger/'  is  the  cause  of  athrepsia.  The 
above  term  is  used  in  contradistinction  to  hunger  as 
usually  thought  of,  which  is  due  to  a  lack  of  food  to 
appease  the  appetite. 

While  a  considerable  number  of  the  cases  of  athrep- 
sia are  due  primarily  to  underfeeding,  such  as  by  nurs- 
ing on  dry  breasts  or  in  artificial  feeding  by  the  giving 
of  food  mixtures  which  are  insufficient  to  meet  the  in- 
fant's needs,  either  because  of  a  too  small  quantity  or 
prolonged  feeding  of  an  improperly  balanced  diet  which 
is  too  low  in  some  of  the  necessary  elements,  the  ma- 
jority of  the  cases  follow  in  the  wake  of  the  acute 
nutritional  upsets  which  may  or  may  not  be  based  upon 
previous  errors  in  diagnosis.  Following  such  digestive 
disturbances  the  time  is  soon  reached  when  even  in  the 
presence  of  a  feeding  of  sufficient  calories  which  are 
properly  distributed,  the  functions  have  become  <^n  im- 
p_aired  that  the  products  of  metabolism  cannot  be  utilized 
by  the  body  tissues. 

Pathogenesis.  In  the  American  literature  the  term 
marasmus  is  quite  generally  used  to  describe  the  clinical 
picture  as  presented  by  the  severe  types.  It  was  assumed 
that  the  destructive  changes  in  the  intestinal  glands  f ol- 
io wJn^_cJTronic_Jn^ajTTrnatipn,  with  a  secondary  impair- 
ment of  the  functions  of  absorp_tion_  and  excretion,  were 
the  underlying  pathological  conditions,  which  resulted  in 
an  inanition.  It  is,  however,  rarely  possible  to  demon- 


240  INFANT   FEEDING. 

strate  pathologic  involvement  of  the  secretory  glands, 
even_jn_the__sei£ere  types.  Marriott  has  suggested  that 
due  to  the  fact  that  there  is  an  atrophied  and  poorly 
circulating  blood  stream,  it  must  necessarily  result  in 
inefficient  functioning  of  the  digestive  glands  and  a  di- 
minished absorption  from  the  intestinal  tract,  both  of 
which  would  necessarily  be  important  factors  in  the 
development  of  the  clinical  picture. 

Every  organ  of  the  body  suffers  more  or  less  from 
the  effects  of  an  insufficient  food  supply.  The  blood 
/volume  is  markedly  diminished  as  well  as  the  volume 
\flow,  so  that  the  amount  of  blood  passing  through  a 
given  part  of  the  body  in  a  unit  of  time  is  much  dimin- 
ished under  the  normal.  Marriott  and  Perkins1  found 
that  in  normal  infants  under  one  year  the  average  blood 
volume  was  9.1  per  cent,  of  the  body  weight.  In  a 
group  of  eleven  athreptic  infants  the  average  was  8  per 
cent,  of  the  body  weight,  the  most  extreme  variation 
being  4.8  per  cent.  It  should  be  remembered  in  con- 
sidering the  figures  for  athreptic  infants  that  these  in- 
fants were  greatly  emaciated  and  under  weight  and  that, 
therefore,  their  blood  volume  was  reduced  to  a  greater 
extent  than  the  percentage  figures  would  at  first  lead 
one  to  believe,  showing  that  there  had  been  a  very  con- 
siderable destruction  of  the  blood  coincident  with  the 
loss  of  other  body  tissues.  Along  with  these  figures  in 
blood  volume  they  also  found  the  volume  flow  to  be 
decreased  often  to  less  than  one-fifth  and  occasionally 
to  less  than  one-tenth  of  the  normal.  During  conva- 
lescence the  volume  flow  increases  with  the  treatment. 
They  also  found  a  concentration  of  the  protein  in  the 
serum  of  these  infants,  also  a  diminution  in  the  red 
blood  cells  and  hemoglobin.  This  may  be  further  ag- 
gravated by  myocardial  weakness  as  the  heart  muscle 
undergoes  the  same  destructive  changes  as  do  the  tis- 


1  Marriott,   W.   McKim:  Amer.  Jour.   Dis.  of  Children,  xx, 
461,  1920. 


ATHREPSIA.  241 

sues  in  general.  The  blood  pressure  sometimes  falls 
below  normal,  due  to  the  fact  that  in  addition  to  the 
other  pathological  conditions  in  the  circulatory  system 
there  is  an  absence  of  increased  viscosity  of  the  blood. 
The  decreased  blood  volume  leads  to  a  constriction  of 
the  arterioles  and  this  leads  to  a  piling  up  of  the  cor- 
puscles in  the  capillary  blood.  The  adipose  tissue  dis-\ 
appears  ancl  there  is  an  autophagia  of  the  protein  ele-  I 
ments  and  a  chronic  loss  of  water  and  of  mineral  sub-  / 
stances.  The  earlier  stage  may  be  described  as  one  of 
the  hypo-athrepsia  and  the  late  severe  types  as  that  of 
athrepsia.  In  the  breast-fed  the  severe  types  are  rarely 
seen  unless  preceded  by  intercurrent  disease.  In  the 
artificially  fed  the  stage  of  hypo-athrepsia  may  progress 
to  athrepsia  even  after  the  primary  digestive  disturbances 
have  subsided  and  in  the  presence  of  insufficient  or  im- 
proper diet.  This  condition  is  especially  prone  to  de- 
velop in  the  environment  of  institutions  and  asylums 
unless  the  nursing  care  includes  a  sufficient  amount  of 
"mothering"  and  massaging  of  the  infants.  The  super- 
vision of  the  feeding  of  infants  is  of  extreme  import- 
ance, so  that  they  may  be  sure  of  obtaining  their  diet 
in  its  entirety  and  while  it  is  warm. 

The  great  and  sudden  fluctuations  in  weight,  as  seen 
in  this  condition,  must  in  the  first  place  be  due  to  loss 
of  water  and  salts,  while  the  disintegration  of  the  body 
substance,  other  than  the  blood,  including  the  cells,  fur- 
nishes only  a  smaller  proportion  of  the  loss  of  weight 
which  occurs. 

Further,  the  abnormal  splitting  of  sugar  and  fats  con- 
tained in  the  food  produces  exressive  amounts  of  acids 
in  the  intestines,  which  results^  in  the  loss  of  alkali  salts, 
fij^t,  through^neutralization  of  the  acids  formed  in  the 
intestinal  tract  from  the  food,  and  secondly,  through  salt 
losses  due  to  excessive  intestinal  secretion,  due  to  irri- 
tation of  the  bowel.  As  a  result  of  such  enteral  loss 
of  salts  an  increased  NH-excretion  takes  place,  which 

16 


242  INFANT   FEEDING. 

is  evidenced  clinically  by  increase  of   ammonic 
urine. 

To  cover  these  losses,  salts  deposited  in  the  tissues 
are  in  part  withdrawn,  and  finally  the  cells  themselves 
are_destroved  through^being^depriyed  of  their  salt  con- 
tent (mineral  jiunger).  It  should  be  remembered  that 
an  abnormal  fat  metabolism  is  frequently  the  essential 
factor  in  the  etiology  of  this  condition,  due  to  an  over- 
stepping of  the  fat  tolerance.  And  further,  that  fer- 
mentative changes  in  the  carbohydrates  produce  increased 
acidity  of  the  contents  of  the  intestinal  canal,  and  so 
enhance  the  action  of  fats.  Both  of  these  may  be  causa- 
tive factors  in  the  development  of  diarrhea.  While  there 
is  usually  an  excess  of  protein  loss  over  protein  assimi- 
lation, the  tolerance  for  proteins  is  usually  less  affected. 
Because  of  the  loss  of  nitrogenous  substances,  due  to  a 
relative  excess  in  excretion  of  NH,  proteins  must  be 
utilized  in  the  diet  to  counteract  these  losses. 

There  is  no  increase  in  the  osmotic  pressure  of  the 
blood  and  hence  no  diminution  in  the  amount  of  urine 
secreted  and  no  accumulation  of  the  urinary  waste  prod- 
ucts of  the  body.  Such  acidosis  as  may  occur  is  to  be 
ascribed  to  causes  other  tjian  retention  of  the  acid  prod- 
ucts by  the  kidney.  The  acidosis  is  probably  in  part  due 
to  the  diminished  volume  flow  of  the  blood  through  the 
tissues  and  to  a  lesser  extent  to  the  production  of  ace- 
tone bodies,  the  result  of  partial  starvation.  Acidosis 
is,  however,  by  no  means  a  prominent  feature  of  this 
condition  and  rarely  calls  for  alkali  therapy. 

Increased  peristalsis  in  diarrheal  conditions  results  in 
further  inanition,  due  to  the  passing  of  undigested  food 
through  the  intestinal  tract.  All  of  this  results  in  de- 
creased assimilation  of  food  necessitating  the  burning 
of  the  infant's  own  body  for  fuel.  The  stored  carbo- 
hydrates (glycogen)  and  fat  are  first  used  and  later  also 
the  body  protein  is  consumed.  When  this  latter  stage 


ATHREPSIA.  243 

is  reached  the  maintenance  of  life  for  any  considerable 
time  is  impossible. 

In  these  infants  in  the  presence  of  impaired  function 
on  the  part  of  the  digestive  tract  it  is  quite  possible  that 
there  may  be  an  invasion  of  the  upper  intestinal  tract 
by  a  bacterial  flora  which,  under  normal  conditions,  does 
not  thrive  in  this  region.  This  may  act  in  two  ways, 
by  interference  with  the  normal  processes  of  digestion 
and  absorption  in  the  region  involved,  and  by  the  setting 
up  of  inflammatory  processes  which  may  result  in  the 
involvement  of  the  entire  tract  with  the  development  of 
diarrhea. 

Marriott1  believes  that  the  comparative  buffer  value 
of  the  food  which  the  infant  is  receiving  may  be  a  factor 
in  the  development  of  malnutrition  in  some  infants.  By 
buffer  value  is  meant  the  capacity  to  unite  relatively  large 


amounts  of  acid  or  alkali  without  a  change  in  chemical 
reaction.  If  the  same  amount  of  hydrochloric  acid  is 
added  to  equal  volumes  of  human  milk  and  cow's  milk 
it  is  found  that  the  acidity  of  the  human  milk,  expressed 
in  terms  of  hydrogen  ion  concentration,  is  far  greater. 
When  milk  enters  the  stomach  of  a  normal  breast-fed 
infant  gastric  juice  is  secreted  in  such  amounts  that  the 
stomach  contents  ultimately  reach  a  certain  degree  of 
acidity.  This  acidity,  expressed  in  terms  of  H-ion  con- 
centration, averages  about  1X10 — 5,  which  is  the  opti- 
mum concentration  for  rennin  action  and  is  sufficient 
to  markedly  inhibit  bacterial  growth  (Hahn2).  Sup- 
pose, however,  cow's  milk,  instead  of  breast  milk,  is  fed : 
If  the  same  amount  of  gastric  juice  is  secreted,  it  is 
entirely  insufficient  to  render  the  stomach  contents  acid 
to  anywhere  near  the  same  optimum  degree.  To  bring 
cow's  milk  to  the  optimum  acidity  of  1X10 — 5,  at  least 
three  times  as  much  hydrochloric  acid  is  required  as  in 


1  Marriott,  W.   McKim:  Amer.   Jour.  Dis.  of  Children,  xx, 
461,  1920. 

2  Hahn:  Am.  Jour.  Dis.  of  Children,  vii,  305,  1914. 


244  INFANT   FEEDING. 

the  case  of  human  milk.  (This  may  readily  be  demon- 
strated by  titrating  breast  milk  and  cow's  milk  with 
diluted  hydrochloric  acid,  using  as  an  indicator  neutral 
red  which  changes  color  at  a  hydrogen  ion  concentration 
of  about  IX 10— 5.) 

It  is  interesting  to  note  that  those  foods  which  have 
been  found  empirically  to  be  the  best  tolerated  by  athrep- 
tic  infants  are  those  which  have  a  low  buffer  value  or 
in  which  the  buffer  is  already  partly  neutralized  byacid. 
Breast  milk,  well  diluted  cow's  milk  with  added  carbo- 
hydrate, lactic  acid^rmlk  and  protein  milk  are  examples. 

f     Symptoms.    The  cardinal  symptoms  of  athrepsia  as 
J  concern  nutrition  are  the  inability  to  utilize   food  and 

I  the  negative  nitrogen  and  mineral  salt  balance.  The 
clinical  picture  presented  is  that  of  a  wasted  infant, 
which  may  be  of  any  degree  of  severity.  It  is  often 
impossible  to  interpret  the  beginning  of  this  severe  form 
of  nutritional  disturbance.  As  a  rule  there  is  a  history 

\  of  repeated  minor  disturbances  with  a  gradual  impair- 

I  ment  of  metabolism.  In  other  cases  it  may  develop  more 
rapidly  and  this  is  especially  true  in  the  presence  of 
diarrheal  attacks.  Characteristic  of  the  severer  types 
is  the  development  of  diarrhea  upon  increased  feeding 
and  continued  weight  loss  when  the  diet  is  insufficient 
to  meet  the  infant's  needs.  Often  it  is  preceded  by  an 
acute  parenteral  infection  or  the  lighting  up  of  a  chronic 
infection,  such  as  otitis,  pyelitis,  or  bronchitis.  The  ad- 
vanced cases  present  the  following  clinical  picture : 

1.  Lack_of_ability  to  assimilate  food  is  pathognomonic 
o£_lhis^£ondition.  The  paradoxical  reaction  to  food, 
mentioned  in  the  two  preceding  stages  of  nutritional  dis- 
turbances, becomes  here  a  striking  and  serious  phe- 
nomenon. Starvation  or  the  institution  of  the  hunger 
day  as  a  therapeutic  measure  in  these  infants  not  infre- 
quently results  in  an  inanition  which  is  fatal  to  the  in- 
fant. Again,  too  rapid  increases  in  the  diet  are  equally 
serious,  and  not  infrequently  precipitate  alarming  and 


ATHREPSIA. 


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246  INFANT   FEEDING. 

fatal  symptoms.     When  the  condition  has  progressed  to 
this  degree,  human  milk  alone  offers  hope  of  recovery. 

2.  Loss  in  weight  is  the  second  cardinal  symptom  of 
athrepsia,  due,  as  the  name  of  this  condition  suggests, 
to  disintegration  of  the  body  substance.     This  may  be 
slight  in  the  beginning,  and  in  the  light  cases;    in  the 
later  stages  and  in  severer  cases,  however,  it  is  often 
sudden  and  rapid,  and  may  reach  daily  losses  from   1 
to  3  ounces  (30  to  100  Gm.),  resulting  eventually  in  a 
picture  of  marasmus.     The  baby  becomes  thin,  emaci- 
ated, wrinkled,  with  prominent  ribs,  covered  with  tightly 
drawn  skin,  and  with  intercostal  spaces  deeply  marked 
(skeleton-like).     The  tissues  are   soft  and   flabby,   the 
muscles  either  relaxed,  or  hypertonic,  the  abdomen  pro- 
tuberant, usually  distended;    the  color,  pale  first,  later 
changing  to  characteristic  grayish-white,  with  more  or 
less  cyanotic  lips,  fingers  and  toes.     The  mouth  appears 
large,  the  cheeks  sunken,  and  the  facial  expression  anxi- 
ous and  serious.     These  characteristics  give  to  the  in- 
fant the  appearance  of  a  wrinkled,  old  man.     As  has 
been  previously  stated,  in  the  earlier  stages,  these  babies 
are  irritable  and  apparently  in  constant  distress,  cry  a 
great  deal,  and   are   excessively  hungry.      In  the   later 
stages,  however,  they  are  often  apathetic,  and  apparently 
too  weak  to  perform  voluntary  movements.     When  they 
have    reached   this   stage,    they   are    subject   to    sinking 
spells — that  is,  periods  in  which  their  vitality  is  very  low. 
These    may    become    very    alarming,    and    often    result 
fatally. 

3.  Vomiting  is  frequent. 

4.  The  hunger  is  often  very  great,  and  extremely  dif- 
ficult to  satisfy. 

5.  Subnormal  temperatures,  ranging  from  96°  to  98° 
F.,  with  an  irregular  daily  curve,  is  the  rule.     The  tem- 
perature can  easily  be  raised  to  100°  F.  or  more  by  the 
application  of  artificial  heat  (hot-water  bottles,  etc.),  and 


ATHREPSIA.  247 

can  sink  quite  as  rapidly  and  alarmingly  when  the  arti- 
ficial heat  is  removed. 

6.  The  pulse  is  often  slow  and  small,  and  the  heart- 
beats weak,  and  often  only  one  heart  tone  is  heard  at 
the  apex.     The  blood  is  thin,  pale,  and  has  a  low  hemo- 
globin and  red  cell  count.     There  may  be  a  moderate 
leucocytosis.     Collapse  is  likely  to  result  from  circula- 
tory failure,  suddenly  and  without  warning. 

7.  Respiration  becomes  rapid,  and  the  expirations  pro- 
longed.    The  breathing  becomes  irregular,  even  to  the 
Cheyne-Stokes  type. 

8.  The  sensorium  is  not  involved  in  these  infants,  and 
when  not  too  weak  they  take  cognizance  of  their  sur- 
roundings, are  alert,  and  sleep  but  little. 

9.  The  urine*  usually  shows  an  increased  ammonia  co- 
efficient.    It  may  contain  albumin,  but  very  ^arely^ sugar. 

10.  The    stools   are    variable,    mostly   dyspeptic,   occa- 
sionally diarrheal.     In  the  earlier  stages  and  in  periods 
of    remissions   they    may    be    quite    firm  (soap    stools), 
again  soft  and  firm  stools  may  alternate.     The  hunger 
stool — small,  dark,  and  containing  much  mucus — is  com- 
mon, especially  in  advanced  cases,  with  an  inability  to 
take  proper  diet.     Dark-brown,  black,  and  tarry   stools 
indicate,  usually,  hemorrhages  from  ulcers  in  duodenum 
(Helmholtz).    We  therefore  learn  to  recognize  the  char- 
acter of  the  stools  as  being  only  of  secondary  importance 
in  the  diagnosis,  and  also  of  secondary  importance  for 
treatment.     We  must  not  be  misled  into  further  starva- 
tion because  of  temporary  changes   in   character,   even 
for  the  worse,  of  the  stool,  clue  to  the  changes  in  the 
diet  instituted  for  therapeutic  purposes. 

11.  These  infants  are  peculiarly  susceptible  to  infec- 
tions, and  even  slight  infections  of  the  skin,  respiratory, 
gastro-intestinal,   and    genito-urinary   tracts,    may   prove 
fatal. 

12.  Edema,  cyanosis,  and  a  more  or  less  generalized 
purpura  are  not  infrequently  forerunners  of  an  impend- 


248  INFANT   FEEDING. 

ing  death.  The  development  of  edema,  with  correspond- 
ing gain  in  weight,  may  lead  to  the  conclusion  that  the 
infant  is  improving.  During  this  stage  there  is  always 
great  danger  of  the  development  of  diarrheal  complica- 
tions. 

13.  Acidosis  may  develop  and  is  probably  in  part  due 
to  the  diminished  volume  flow  of  blood  through  the  tis- 
sues, and  to  a  lesser  extent  to  the  development  of  ace- 
tone bodies,  the  latter  due  in  part  to  starvation.  As 
there  is  usually  no  diminution  in  the  amount  of  urine 
secreted  when  sufficient  fluids  are  administered,  the  acido- 
sis  is  not  due  to  an  accumulation  of  urinary  waste  prod- 
ucts in  the  body.  Acidosis  is  usually  not  a  prominent 
feature.1 

Diagnosis.  The  diagnosis  in  severe  cases  may  be 
made  from  the  clinical  picture  of  the  condition,  but  it 
is  necessary  to  exclude  emaciation  due  to  tuberculosis, 
syphilis  and  cachexia  caused  by  other  disease,  and  also 
by  simple  inanition,  due  to  prolonged  underfeeding.  This 
is  to  be  based  on  the  history  and  .examination  of  the 
infant.  In  lighter  cases  it  is  necessary  to  differentiate 
especially  from  disturbed  metabolic  balance  and  from 
simple  dyspepsia,  since  the  treatment  which  improves 
these  conditions  may  do  considerable  harm  in  infants 
suffering  from  athrepsia.  The  status  praesens  is  not 
sufficient  for  making  the  diagnosis,  since,  as  previously 
mentioned,  remissions  with  stationary  weight  and  good 
stools  often  occur.  In  these  cases  the  history  is  of  ut- 
most importance:  repeated  diarrhea,  loss  in  weight  and 
febrile  infections  should  lead  one  to  suspect  athrepsia. 
The  positive  diagnosis  is  made  upon  the  reaction  of  the 
infant  to  food.  If  on  somewhat  increasing  the  diet  a 
marked  and  severe  paradoxical  reaction  appears  (diar- 
rhea, loss  of  weight,  and  occasionally  fever),  athrepsia 
should  be  suspected. 


1  Marriott,  W.  McKim ;  Am.  Jour.  Dis.  of  Children,  xx,  461, 


ATHREPSIA.  249 

Prognosis.  We  must  remember  that  while  pri- 
marily the  picture  of  the  disease  is  a  nutritional  one,  the 
death  is  frequently  brought  about  by  infection.  The 
younger  the  infant  the  greater  is  the  mortality  and  this 
is  most  especially  true  during  the  first  months  of  life, 
when  breast  milk  is  not  obtainable.  Among  older  in- 
fants the  prognosis  is  better.  The  hygienic  conditions 
under  which  the  infant  is  treated  and  the  care  with  which 
the  treatment  is  carried  out  are .  important  factors.  On 
the  whole,  these  infants  do  better  in  the  home  than  in 
the  general  wards  of  institutions,  due  to  the  fact  that 
they  require  a  great  deal  of  individual  nursing  care.  In 
institutions  there  is  also  the  possibility  of  infection 
through  exposure.  Convalescence  is  usually  slow  and 
may  cover  a  period  of  several  months  in  the  severe  types. 

The  prognosis  depends  on  the  following  factors: 
(1)  The  stage  of  athrepsia.  When  the  loss  of  weight 
has  reached  one-third  of  the  body  weight  (Quest's  fig- 
iures),  then  the  reparation,  under  any  treatment,  seems 
to  be  impossible.  (2)  The  nature  of  the  dietetic  treat- 
ment, and  especially  the  possibility  of  feeding  with  hu- 
man milk.  If  one  avoids  the  common  errors,  even  the 
severe  cases  may  be  saved,  except  when  the  treatment 
is  started  too  late.  (3)  The  extent  of  the  lowered  im- 
munity. The  prognosis  should  always  be  guarded. 

Improvement  is  common, ,  even  in  severe  cases,  but 
there  is  a  great  tendency  to  sinking  spells  and  collapse. 
Death  in  these  cases  is  sometimes  remarkably  sudden. 
It  usually  occurs  in  one  of  the  following  ways:  (1)  By 
sudden  syncope.  (2)  By  apparent  paralysis  of  the  res- 
piratory center.  Periods  of  apnea  usually  precede  the 
latter.  There  is  no  disturbance  of  consciousness.  The 
face  looks  gray,  and  the  eyes  are  staring.  The  breath- 
ing becomes  irregular  and  slow,  the  heart  weakens,  the 
temperature  sinks  far  below  normal.  Cyanosis  increases, 
and  breathing  gradually  stops.  Sometimes  the  heart 
stops  first.  Such  death  may  extend  over  days. 


250  INFANT   FEEDING. 

Treatment.  Prophylaxis  is  the  key-word  to  success- 
ful treatment.  A  recognition  and  proper  interpretation 
of  minor  nutritional  disturbances  will  avoid  the  graver 
conditions. 

For  a  proper  conception  of  the  therapeutic  needs  we 
must  recognize : 

1.  That  we  have  a  chronic  condition  which , is  subject 
to  acute  catastrophes. 

2.  That  the  younger  the  infant  and  the  greater  the 
preceding  dietetic  errors,  the  graver  are  the  consequences 
of  athrepsia. 

3.  That  starvation  is  dangerous. 

4.  That  food  is  assimilated  with  difficulty. 

5.  That  the  downward  weight-curve  is  likely  to  drop 
suddenly  with  improper  feeding  and  intercurrent  infec- 
tion. 

Three  essentials  are  necessary  to  the  successful  treat- 
ment of  the  majority  of  cases  of  athrepsia:  (1)  Avoid- 
ance of  prolonged  starvation;  (2)  the  administration  of 
sufficient  inert  fluids,  and  (3)  human  milk.  It  is  the 
misfortune  of  most  of  these  infants  to  have  their  ab- 
normal stools — or  more  commonly,  the  hunger  stools 
previously  described — interpreted  as  an  indication  for 
starvation,  regardless  of  the  fact  that  the  baby  is  already 
starving.  It  has  been  our  experience  not  only  to  have 
seen  one  day  of  starvation,  but  repeated  periods  of 
starvation,  the  rule,  because  of  misinterpretation  of  the 
significance  of  the  "starvation  stools."  A  single  day  of 
starvation  is  often  sufficient  to  kill  an  advanced  case, 
and  even  prolonged  underfeeding,  below  60  calories  per 
kilogram  (the  amount  required  to  sustain  the  body  equi- 
librium), has  a  very  harmful  effect.  Starvation  from 
without  is  thus  added  to  inanition  from  within. 

1.  Water  Administration.  Athreptic  infants  must  at 
all  times  receive  sufficient  fluids  to  meet  their  needs. 
They  should,  during  the  twenty-four  hours,  be  given 
approximately  one-fifth  of  their  body  weight  in  water, 


ATHREPSIA.  251 

including  that  contained  in  the  food  administered.  The 
water  or  weak  tea  feeding  should  be  set  aside  in  a  steril- 
ized bottle  and  given  between  feedings. 

2.  Feeding  With  Human  Milk.  It  must  be  given  in 
moderate  quantity,  best  guarded  by  drawing  off  and  feed- 
ing, as  these  infants  drink  too  rapidly  (always  hungry), 
and  do  not  stand  large  amounts.  About  200  to  300  mils 
daily  is  enough  to  sustain  the  infants  temporarily  (70 
calories  per  kilogram  is  sustaining — Rosenstern).  Feed 
often;  ten  feedings  may  be  given,  one  every  two  hours 
(20  to  30  mils),  weak  tea  or  saccharin  water  ad  libitum 
between  feedings.  The  daily  quantity  should  be  in- 
creased as  rapidly  as  possible  (at  least  every  other  day), 
until  not  later  than  after  seven  to  ten  days  about  100 
calories  (130  to  150  mils)  per  kilogram  are  administered. 
The  number  of  feedings  should  gradually  be  decreased 
as  the  condition  improves,  and  direct  nursing  on  the 
breast  may  be  tried  later,  but  the  danger  of  overfeeding 
must  not  be  overlooked.  There  is  usually  little  danger 
of  overfeeding  when  there  are  no  gastro-intestinal  symp- 
toms and  the  diet  consists  exclusively  of  breast  milk. 
Because  of  the  decreased  weight  little  can  be  expected 
in  the  way  of  rapid  progress  until  the  diet  reaches  a 
quantity  which  would  approximate  100  calories  per  kilo- 
gram for  the  average  full-weight  infant  at  a  given  age, 
which  not  infrequently  means  150  to  200  calories  per 
kilogram  for  the  athreptic  infant.  The  diet  should  be 
steadily  increased  as  long  as  there  are  no  gastro-intestinal 
disturbances. 

Weight  may  still  not  improve  for  some  time.  This 
Keller  calls  "reparation  stage."  Even  on  feeding  with 
human  milk  there  is  a  shorter  or  a  longer  period  of 
stationary  weight  (depending  on  the  severity  of  the 
case),  which,  however,  is  accompanied  by  improvement 
of  the  symptoms.  Those  who  have  not  had  experience 
in  these  cases  may  be  inclined  to  blame  the  wet-nurse, 
and  advise  a  change.  In  the  stage  of  reparation,  how- 


252  INFANT   FEEDING. 

ever,  the  body  is  being  reconstructed,  without  being  able 
to  put  on  weight,  this  being  partially,  at  least,  due  to 
still  deficient  absorption,  and  partially  also  to  the  fact 
that  the  human  milk,  containing  comparatively  small 
quantities  of  proteins  and  salts,  furnishes  only  a  limited 
quantity  of  material  for  rebuilding  of  the  body.  Only 
after  this  period  the  gain  in  weight  begins  and  it  may  be 
shortened  by  feeding  daily  100  mils  of  boiled  buttermilk 
or  skim  milk,  which  is  rich  in  salts  and  proteins,  both  of 
these  substances  hastening  weight  increase.  This  is  not 
to  be  done  until  after  the  second  or  third  week  of  treat- 
ment, and  with  a  close  observation  of  the  results.  It 
may  be  fed  by  mixing  with  and  distributing  through  the 
expressed  breast  milk. 

It  may  be  necessary  to  add  carbohydrates  to  the  breast 
milk,  more  especially  when  the  quantity  at  hand  is  in- 
sufficient. This  should  be  done  with  considerable  care, 
the  daily  quantity  added  being  increased  by  four  to  eight 
grams  at  a  time.  This  may  be  given  in  the  form  of  cane 
and  milk  sugar  or  corn  syrup.  In  older  infants  the 
cereal  gruels  may  be  added  to  the  diet  during  the  repara- 
tion stage. 

The  complete  recovery  is  not  to  be  expected  sooner 
than  in  two  to  three  months.  And. only  then  should  the 
return  to  artificial  feeding  be  thought  of.  The  weaning 
should  be  preceded  by  experimental  administration  of 
a  small  quantity  of  whole  cow's  milk,  as  there  is  a  pos- 
sibility of  idiosyncrasy  to  cow's  milk. 

3.  Artificial  Feeding.  If  there  is  no  possibility  of 
feeding  an  infant  suffering  from  athrepsia  otherwise 
than  with  artificial  food  mixtures,  then  much  the  same 
rules  are  to  be  followed  as  have  been  given  for  diar- 
rheal  disturbances.  As  has  been  previously  stated,  there 
is  a  great  need  for  food  and  there  always  exists  the 
danger  of  overfeeding,  which  holds  particularly  true  in 
those  who  must  be  put  upon  artificial  diet.  We  must, 
therefore,  often  be  satisfied  with  a  very  slow  stage  of 


ATHREPSIA.  253 

reparation  and  expect  little  gain  in  weight  until  the  in- 
fant is  able  to  assimilate  sufficient  quantities  of  food, 
which  may  mean  a  diet  with  food  value  considerable 
over  that  required  by  the  normal  infant.  Our  best  re- 
sults have  been  obtained  by  the  administration  of  whole 
and  skim  lactic  acid  milk  and  albumin  milk  (protein). 
The  two  latter  foods,  however,  have  a  very  low  caloric 
value,  which  must  be  increased  by  the  addition  of  sugar 
and  starch. 

It  may  be  necessary  to  use  boiled  whole  or  fresh  skim 
milk  when  the  lactic  acid  milk  or  albumin  milk  is  not 
available.  The  feeding  with  these  foods  will  be  de- 
scribed in  detail.  Whenever  possible  lactic  acid  milk 
should  be  used  as  the  basis  of  the  feeding.  The  feeding 
may  be  started  with  fat-free  lactic  acid  milk  to  which 
small  quantities  of  carbohydrates  have  been  added.  This 
may  be  followed  by  a  feeding  with  equal  parts  of  whole 
and  fat-free  lactic  acid  milk. 

In  mild  cases  feedings  of  60  mils  (2  ounces)  eight 
times  daily,  and  in  severe  cases  ten  or  twelve  feedings 
of  30  mils  (1  ounce),  may  be  given  in  twenty-four  hours 
during  the  first  two  days. 

Gradually  the  fat-free  may  be  replaced  by  whole  lac- 
tic acid  milk  until  these  infants  receive  one-fifth  or  one- 
sixth  of  the  body  weight  of  this  food  per  day.  In  very 
young  infants  the  change  to  whole  lactic  acid  milk  must 
of  necessity  be  somewhat  slower. 

The  carbohydrates  are  usually  added  in  a  slowly  fer- 
mentable form,  such  as  the  maltose  and  dextrin  com- 
pounds, which  are  usually  started  by  the  addition  of  four 
grams  per  kilogram  (two  grams  per  pound)  and  in- 
creased until  eight  grams  or  more  per  kilogram  of  body 
weight  are  added.  The  flour  ball  or  dextrinized  barley 
flour  may  be  used  to  further  supplement  the  carbo- 
hydrates by  the  addition  of  an  amount  equal  to  one- fourth 
of  that  of  the  sugar  added. 


254  INFANT   FEEDING. 

Marriott  has  more  recently  recommended  the  use  of 
commercial  "glucose,"  otherwise  known  as  "corn  syrup," 
which  is  a  mixture  of  dextrin,  glucose  and  maltose,  as 
an  available  form-  of  carbohydrate  in  use  in  these  cases. 
Of  the  total  carbohydrates  present  in  corn  syrup  dex- 
trin makes  up  approximately  55  per  cent.,  maltose  30 
per  cent.,  and  glucose  15  per  cent.  •  He  starts  the  diet 
by  the  addition  of  3  per  cent,  to  the  lactic  acid  milk  and 
if  no  diarrhea  occurs,  he  increases  it  gradually,  depend- 
ing upon  the  infant's  tolerance  and  the  amount  of  food 
necessary  to  cause  a  gain  in  weight.  In  some  infants 
the  amount  of  added  sugar  may  advantageously  be  as 
high  as  10  per  cent. 

Infants  may  be  fed  on  these  corn  syrup,  lactic  acid 
milk  mixtures  for  an  indefinite  period  of  time.  As  a 
gain  in  weight  occurs  the  amount  of  sugar  may  be  ad- 
vantageously diminished.  In  infants  approximating  one- 
half  of  their  normal  weight  it  may  be  necessary  to  feed 
as  much  as  160  to  200  calories  per  kilogram  before  there 
is  a  marked  increase  in  weight.  Several  weeks  of  care- 
ful feeding  may  be  required  before  these  amounts  can 
be  approximated.  The  whole  lactic  acid  milk  and  corn 
syrup  mixtures  owe  one  of  their  chief  advantages  to  the 
fact  that  they  are  a  concentrated  food  and  if  the  infant 
can  take  only,  a  limited  number  of  ounces  at  a  feeding 
and  only  a  limited  number  of  feedings  in  a  day,  the 
requirements  for  a  high  caloric  intake  can  be  solved  by 
the  administration  of  such  a  mixture.  A  mixture  made 
from  whole  milk  to  which  the  corn  syrup  is  added  will 
have  a  food  value  varying  from  25  to  30  calories  or 
more  per  ounce,  depending  upon  the  amount  of  the  syrup 
added.1 


1  Karo — blue  label  syrup  contains  from  80  to  85  per  cent,  of 
carbohydrate  by  weight,  as  its  specific  gravity  is  high  (ap- 
proximately 1.40),  it  contains  from  110  to  120  per  cent,  of  carbo- 
hydrate by  volume.  The  thick  syrup  is  somewhat  difficult  to 
handle  and  to  mix  with  milk.  It  is  more  convenient  to  prepare  a 
diluted  syrup.  Mixing  45  volumes  of  the  thick  syrup  with  55 
volumes  of  water  gives  a  thin  syrup  containing  approximately  50 


ATHREPSIA.  255 

The  individual  meals  should  be  increased  so  as  to  meet 
the  infant's  caloric  needs  as  rapidly  as  the  condition 
allows. 

The  need  of  the  athreptic  infant  for  food  containing 
sufficient  vitamines  can  be  demonstrated  clinically  by  the 
rapid  improvement  noted  upon  the  proper  rounding  out 
of  the  diet.  For  this  reason  the  infant  should  not  be 
kept  for  too  long  a  time  on  a  food  deficient  in  this  sub- 
stance. Cod-liver  oil  should  be  added  to  the  diet,  be- 
ginning in  small  amounts,  as  soon  as  the  infant's  con- 
dition will  warrant  it.  Orange  juice  should  also  be 
started  early  and  increased  until  one  ounce  or  more  is 
taken  daily. 

Good  results  in  the  treatment  of  athreptic  infants  are 
obtained  by  feeding  them  with  albumin  milk. 

The  advantage  of  the  treatment  with  albumin  milk 
consists  in  the  fact  that  it  is  possible  to  reach  sufficient 
feeding  quantities  more  rapidly* than  with  most  other  arti- 
ficial foods,  without  the  danger  of  exciting  anew  the  fer- 
mentative processes.  Thereby  the  danger  of  inanition  is 
avoided  and  reparation  is  accelerated. 

In  the  mild  cases  of  athrepsia  we  start  after  an  inter- 
val of  six  hours  on  tea,  with  administration  of  300  mils 
of  albumin  milk,  with  an  addition  of  3  per  cent,  of 
maltose-dextrin  preparations  (milk-sugar  is  not  advis- 
able, and  even  the  cane-sugar  is  not  so  reliable),  divided 
into  five  or  six  meals,  and__with_  further  addition  of 
tea.  In  the  days  that  follow,  without  paying  any  at- 
tention to  the  stools,  the  quantity  of  albumin*  milk  is 
increased,  every  other  day  by  100  mils.  In  the  presence 
of  firm  stools  it  is  increased  even  more  rapidly,  until  a 
daily  quantity  of  180  to  200  mils  per  kilogram  (3  ounces 


per  cent,  of  carbohydrate.  One  hundred  c.c.  of  this  by  volume 
may  be  considered  as  containing  50  Gm.  of  carbohydrate.  Such 
a  thin  syrup  is  measured  in  a  graduate  and  added  to  the  whole 
lactic  acid  milk.  The  mixture  should  not  be  agitated  sufficiently 
to  separate  the  fat  as  butter.  The  mixture  is  not  further  steri- 
lized, but  is  kept  in  a  refrigerator  until  used.  As  such  mixtures 
are  very  thick,  a  nipple  with  a  large  hole  must  be  used  in  feeding. 


256  INFANT   FEEDING. 

per  pound  body  weight)  is  reached.  A  total  daily  quan- 
tity of  1000  mils  of  albumin  milk  is  rarely  to  be  ex- 
ceeded. In  typical  cases  dry  fat-soap  stools  appear  after 
one  to  two  days,  this  is  followed  by  cessation  of  weight 
loss,  and  reparation  proceeds  undisturbed. 

After  the  quantity  of  food  necessary  to  sustain  the 
infant  is  reached,  sugar  may  be  gradually  increased 
from  3  to  5  per  cent.  Dextrinized  starches  in  the  form 
of  flour  ball  (imperial  granum),  or  dextrinized  barley 
flour  in  quantities  of  1  or  2  per  cent,  of  the  mixture,  can 
often  be  added,  to  advantage,  to  albumin  milk. 

In  severer  grade  of  athrepsia  the  intestine  is  allowed 
to  empty  itself  by  a  short  period  of  hunger.  In  spite  of 
the  danger  of  inanition,  six,  or  at  most  twelve,  hours  on 
tea  cannot  be  avoided.  This  is  to  be  followed  by  the 
administration  of  albumin  milk,  best  by  frequent  meals 
(eight  to  ten),  on  the  first  day  200  to  300  mils,  and  then, 
as  previously  advised,  rapid  increase  with  gradual  dimi- 
nution of  the  number  of  meals  and  increase  in  the  addi- 
tion of  carbohydrates.  If  the  initial  loss  in  weight  does 
not  stop  within  three  to  four  days,  and  if  the  child  shows 
languor  and  tendency  to  subnormal  temperature,  then 
the  addition  of  carbohydrates  must  be  increased,  even 
in  the  presence  of  frequent  stools,  until  the  loss  stops. 

If  we  proceed  in  this  way,  then  the  number  of  un- 
successful cases  becomes  considerably  less.  Experi- 
ence has  shown  that  in  albumin  milk  therapy  often  an 
error  is  made  which  frequently  leads  to  failure  by  under- 
feeding. It  should  be  remembered  that  albumin  milk 
has  a  caloric  value  of  only  about  twelve  to  the  ounce, 
and  therefore  this  feeding  must  be  carefully  guarded  to 
avoid:  (1)  Too  slow  initial  increase,  thereby  prolonging 
inanition;  (2)  omission  of  carbohydrates  or  insufficient 
increase  of  the  same;  (3)  repeated  restriction  of  the 
quantity  of  the  food,  or  withholding  carbohydrates  when 
the  temperature  rises  or  diarrhea  reappears.  All  these 
are  to  be  avoided.  Only  when  sudden  loss  in  weight 


ATHREPSIA.  257 

and  violent  diarrhea  set  in,  should  the  total  quantity  of 
the  food  be  reduced.  After  disappearance  of  these  acute 
symptoms  the  increase  must  be  made  as  soon  as  possible. 

In  the  beginning  of  the  treatment  with  albumin  milk, 
exacerbations  similar  to  those  that  occur  on  feeding  with 
human  milk  may  occur,  and  these  should  not  lead  to 
starvation.  Later,  the  gain  is  rapid,  provided  that  suf- 
ficient quantities  of  carbohydrates  have  been  added. 

The  duration  of  feeding  with  albumin  milk  is  about 
six  to  eight  weeks  for  the  younger  infants,  and  four  to 
six  weeks  for  the  older  infants.  After  this  time  the 
conditions  change  usually  to  such  an  extent  that  ordinary 
milk  mixtures,  corresponding  to  the  child's  age  and 
weight  may  well  be  taken.  The  change  is  best  made  by 
replacing  all  the  feedings  of  albumin  milk  mixtures  at 
one  time  by  a  weak  boiled  milk  mixture.  This  is  fre- 
quently followed  by  bad  stools  for  a  day  or  two,  which 
should  not  lead  one  to  discontinue  the  new  diet.  The 
quantity,  however,  should  not  be  further  increased  until 
they  show  some  improvement. 

If  a  relapse  occurs,  then  it  is  necessary  to  return  to 
feeding  with  albumin  milk  for  some  additional  time. 

One  may  speak  of  a  complete  cure  of  this  nutritional 
disturbance  in  an  infant  only  when,  after  discontinua- 
tion of  albumin  milk  and  return  to  the  usual  milk  mix- 
tures, with  careful  dosage,  the  development  proceeds 
without  any  disturbance. 

Medicinal  Treatment.  This  is  practically  limited  to 
stimulation  in  the  presence  of  collapse  and  sinking  spells, 
and  the  favorite  stimulant  is  camphor  given  intra- 
muscularly in  the  form  of  a  sterilized  camphorated  oil 
(five  to  ten  drops  every  two  to  four  hours).  Aromatic 
spirits  of  ammonia  and  caffeine  sodium  benzoate  are 
valuable.  Epinephrin,  in  doses  of  three  to  five  minims  of 
%ooo  solution,  administered  intramuscularly,  may  be  used 
in  an  emergency  in  repeated  doses.  In  the  severer  types 
blood  transfusion  is  also  indicated. 

17 


258  INFANT   FEEDING. 

After-treatment.  In  extreme  cases  intravenous  in- 
jection of  glucose  solution  may  be  used  to  advantage.  It 
increases,  at  least  temporarily,  the  volume  of  the  blood, 
and  as  a  result  the  volume  flow  through  the  organs  and 
at  the  same  time  furnishes  a  limited  amount  of  food 
which  may  be  of  considerable  value  in  extreme  cases. 

Glucose  may  be  administered  intravenously  in  10  per 
cent,  solution,  in  amounts  not  exceeding  20  mils  per  kil- 
ogram of  body  weight.  It  is  best  given  in  normal  saline 
the  total  amount  not  to  exceed  100  to  200  mils.  (%0  of 
the  body  weight).  It  may  be  preceded  to  great  advantage 
by  giving  150  to  300  mils  of  Ringer  solution  intraperitone- 
ally  one  hour  before.  The  injection  should  be  given  very 
slowly,  and  may  be  repeated  two  or  three  times  a  day. 

Artificial  heat  must  be  applied  in  all  cases  with  a 
decided  tendency  to  low  temperatures.  This  must  not 
be  overdone,  since  the  child's  temperature  can  easily  be 
raised  above  the  normal,  and  act  as  unfavorably  as  sub- 
normal temperature. 


CHAPTER  VI. 
ANHYDREMIA  (ANHYDREMIC  INTOXICATION). 

Synonyms:  Alimentary  intoxication  (Finkelstein). 
Alimentary  toxicosis  (Czerny).  Gastro-enteric  intoxi- 
cation (Holt).  Catarrhal  enteritis,  ileo-colitis.  infec- 
tious diarrhea,  cholera  infantum,  summer  diarrhea. 

The  term  anhydremia  (an-privative,  hydro- water, 
aima-blood)  means  the  opposite  of  hydremia,  an  abnor- 
mal decrease  in  the  relative  proportion  of  the  water  to 
that  of  the  salts  of  the  blood.  This  term,  suggested  by 
Marriott,1  is  used  to  describe  a  general  toxic  state  pre- 
cipitated by  an  insufficient  water  intake  or  an  excessive 
loss  through  diarrhea  and  vomiting,-  and  by  way  of  the 
skin  and  lungs,  and  resulting  in  a  negative  water  balance 
and  a  diminished  blood  volume.  It  is  characterized  by 
a  symptom-complex  in  which  diarrhea  and  irritability 
of  the  central  nervous  system  are  the  most  characteristic 
signs.  The  collapse  and  nervous  symptoms  may  out- 
weigh the  intestinal  symptoms.  Less  frequently  cases 
may  be  seen  unassociated  with  diarrhea  and  which  are 
due  to  insufficient  fluid  intake. 

The  graver  the  preceding  nutritional  disturbances, 
that  is,  the  closer  the  infant  approaches  the  stage  of 
athrepsia,  the  more  readily  does  the  stage  of  anhydremic 
intoxication  develop. 

Etiology.  The  symptom  complex  has  as  its  basis 
a  desiccation  of  the  blood  and  tissues,  the  result  of  an 
increased  excretion  of  water  over  the  intake.  The  end 


Note1 :  In  the  elaboration  of  Chapter  VI  free  use  has  been 
made  of  the  original  articles  of  W.  McKim  Marriott.  See  Patho- 
genesis  of  Certain  Xutritional  Disorders,  Proceedings  of  American 
Pediatric  Society,  xxxi,  1919;  Some  Phases  of  Pathology  of  Nu- 
trition in  Infancy,  Am.  Tour.  Dis.  of  Children,  xx ;  461,  Dec.  1920; 
Severe  Diarrhea  in  Infancy,  M.  Clinics,  N.  Amer.  iv,  717;  Novem- 
ber, 1920. 

(259) 


260  INFANT   FEEDING. 

.results  of  this  abnormal  metabolism  is  a  characteristic 
group  of  symptoms  which  are  in  large  part  directly  at- 
tributable to  the  concentration  of  the  blood  and  its  effect 
upon  the  function  of  the  other  organs. 

The  group  of  symptoms  are  suggestive  of  an  acute 
poison  which  may  result  in  death  and  in  the  majority 
of  instances  leave  no  demonstrable  pathological  findings. 
In  the  absence  of  anatomical  changes  we  are  forced  to 
conclude  that  some  profound  alteration  in  the  chemical 
or  physiological  processes  in  the  body  must  have  oc- 
curred. Czerny,  who  gave  this  clinical  picture  consider- 
able thought,  believes  that  it  was  the  result  of  the  ab- 
sorption of  toxic  substances  of  metabolic  or  bacterial 
origin.  Finkelstein  believed  that  it  was  primarily  due 
to  food  poisoning  and  that  infection  and  constitutional 
abnormalities  acted  as  contributory  factors  to  the  lower- 
ing of  the  infant's  tolerance  for  food,  thereby  impairing 
his  ability  to  utilize  food  without  the  production  of 
harmful  substances.  They  base  their  conclusions  upon 
the  fact  that  the  clinical  picture  is  aggravated  when  a 
relative  excess  of  food  is  given  to  this  class  of  infants. 
Marriott,  in  his  analysis  of  this  group  of  cases,  recog- 
nizes the  bad  effect  of  food  when  given  in  excess  of  the 
infant's  tolerance  but  explains  it  upon  a  different  basis. 
He  emphasizes  the  well  known  fact  that  infants  suffer- 
ing from  diarrhea  have  a  tendency  to  become  worse  when 
food  is  given,  especially  an  excess  of  carbohydrate  or 
fat.  The  result  of  this  is  an  increase  in  the  degree  of 
anhydremia.  If  food  is  given  to  an  infant  who  is  an- 
hydremic,  such  as  a  case  of  athrepsia,  even  though 
diarrhea  is  not  present,  it  is  likely  to  result  in  diarrhea. 
It  is  therefore  evident  that  any  of  the  etiological  factors 
which  may  cause  or  predispose  to  diarrhea  may  be  the 
forerunners  of  the  stage  of  anhydremia,  due  largely  to 
the  loss  of  fluids  through  the  bowels  and  to  a  lesser 
degree  through  vomiting.  The  secondary  picture  of 
acidosis  may  be  superimposed  upon  that  of  anhydremia 


ANHYDREMIA.  261 

with  clinical  evidence  of  an  intoxication.  The  acidosis 
in  these  cases  is  due  to  a  deficient  renal  function  second- 
ary to  the  impaired  circulation  through  the  kidneys  and 
results  in  an  accumulation  of  acid  phosphates  in  the 
blood.1  A  second  factor  may  be  active  in  the  develop- 
ment of  the  acidosis,  in  that  there  is  a  tendency  toward 
accumulation  of  lactic  acid  in  the  tissues  from  partial 
cell  asphyxia  which  is  also  dependent  upon  the  dimin- 
ished blood  flow  secondary  to  a  diminished  blood  volume. 
Uremia  may  be  superimposed  in  this  stage.  We  believe 
that  we  are  justified  in  assuming  with  Marriott  that  the 
absorption  of  unsplit  sugars  into  the  blood  through  in- 
jury of  the  intestinal  mucosa  and  the  products  of  fat 
metabolism,  as  suggested  by  Finkelstein,  are  not  the 
underlying  etiological  factors.  However,  sugar  may  in- 
crease the  symptoms  of  intoxication  through  increasing 
the  diarrhea  and  water  loss.  Fats  and  salts  may  have  a 
similar  action.  Sugar  further  furnishes  a  good  culture 
medium  for  the  growth  of  abnormal  bacteria  and  for  the 
normal  intestinal  bacterial  flora  which  under  abnormal 
conditions  may  inhabit  the  upper  intestinal  tract.  The 
abnormal  flora  may  enter  from  above  through  infected 
food  or  ascending  from  below  to  higher  levels,  they  may 
invade  the  upper  area  in  the  small  intestines  in  abnormal 
numbers,  due  to  diminished  resistance  of  the  individual. 
Again,  in  disturbed  metabolism  an  excess  of  sugar  may 
reach  the  lower  bowel  and  stimulate  abnormal  bacterial 
activity.  It  is  also  possible  that  the  protein  split  product 
(amino-acids)  may  give  rise  to  abnormal  amounts  of 
histamine  and  allied  substances  which  are  very  irritating 
to  the  intestinal  mucosa  and  thereby  cause  or  aggravate 
the  diarrhea.  It  is  therefore  evident  that  all  factors 
which  cause  nutritional  disturbances  can  be  active  fac- 
tors in  the  causation  of  a  state  of  anhydremia  with  its 


1  Marriott,  W.  McKim  and  Rowland,  J. :  The  influence  of 
acid  phosphate  on  the  elimination  of  ammonia  in  the  urine, 
Arch,  of  Int.  Mcd.,  xxii,  477,  1918. 


262  INFANT  FEEDING. 

secondary  picture  of  intoxication.  Although  frequently 
the  underlying  diarrhea  is  due  to  a  primary  food  dis- 
turbance the  diarrhea  is  more  commonly  seen  following 
a  food  disturbance  secondary  to  some  other  factor. 

Anhydremia  also  frequently  occurs  in  the  absence  of 
diarrhea  when  the  amount  and  character  of  the  food  is 
not  such  as  to  cause  a  gastro-intestinal  disturbance  and 
as  a  secondary  complication  in  infections.  It  is  espe- 
cially common  in  premature  infants  who  are  not  given 
sufficient  inert  fluids  between  feedings,  in  young  infants 
nursing  dry  breasts  and  in  the  presence  of  anorexia  in 
the  course  of  acute  illnesses.  It  is  a  common  condition 
among  infants  suffering  from  intra-cranial  lesions,  such 
as  intra-cranial  hemorrhages,  and  idiots.  Also  in  the 
course  of  acute  infections,  such  as  pneumonia,  otitis 
media  and  pyelitis,  more  especially  during  the  acute 
febrile  stages  associated  with  delirium.  In  all  of  the 
foregoing,  vomiting  may  be  an  active  factor. 

Desiccation  of  the  body  may  therefore  occur  in  a  great 
variety  of  conditions  and  the  symptoms  are  essentially 
the  same,  no  matter  what  the  original  cause,  and  while 
diarrhea  is  by  far  the  most  frequent  etiological  factor, 
it  need  not  necessarily  be  present.  In  the  light  of  our 
present  knowledge  the  terms  "anhydremia"  and  "anhy- 
dremic  intoxication,"  as  suggested  by  Marriott,  are  ac- 
curately descriptive,  the  former  of  the  underlying  fac- 
tor and  the  latter  when  the  toxic  stage  has  been  reached, 
irrespective  of  the  original  cause. 

Symptoms.  Fever.  A  rise  in  temperature  is  one  of 
the  first  symptoms.  It  may  be  slight,  or  it  may  go  up 
to  104°  or  even  106°  F.  The  height  of  the  temperature 
is  not  always  a  direct  indication  of  the  severity ;  in  fact, 
the  several  types  associated  with  athrepsia  may  have  a 
low  temperature.  Prompt  withdrawal  of  the  food  in 
cases  unaccompanied  by  infection  is  usually  as  quickly 
followed  by  a  lower  temperature  when  at  the  same  time 
there  is  sufficient  water  administration  and  retention. 


ANHYDREMIA.  263 

However,  if  the  offending  food  is  continued,  we  soon 
have  other  symptoms  suddenly  and  to  an  alarming  de- 
gree. The  weight  of  evidence  seems  to  strongly  support 
the  view  that  the  action  of  the  administration  of  hyper- 
tonic  solutions  of  sugars  or  salts  is  to  remove  water 
from  the  body  with  resulting  further  dehydration.  The 
assumption  of  Finkelstein,  that  the  continuing  of  the 
diet  resulted  in  the  production  of  pyrogenic  metabolites, 
is  not  tenable.  Fever  as  the  result  of  dehydration  has 
been  repeatedly  observed,  such  desiccation  resulting  in 
interference  with  water  evaporation  through  a  decreased 
circulation  and  secondarily  by  interference  with  excre- 
tion. The  second  factor  of  infection  leading  to  diarrhea 
and  vomiting,  and  dehydration  of  the  body  is  an  added 
causative  factor  in  the  explanation  of  the  fever. 

Rapid  loss  in  weight,  even  one  to  two  pounds  in  a  few 
days.  This  is  mainly  due  to  loss  of  salts  and  water. 

Vomiting  is  frequent  and  may  contain  blood  if  long 
continued. 

The  stools  are  liquid,  usually  numerous,  and  contain 
mucus,  and  occasionally  blood.  In  the  severest  cases — 
cholera  infantum — the  stools  assume  a  rice-water  ap- 
pearance, move  almost  continuously,  and  are  often  asso- 
ciated with  tenesmus,  and  not  infrequently  prolapse  of 
the  rectum.  Exceptionally,  an  obstipation  is  seen  in 
place  of  the  diarrhea,  and  when  this  is  associated  with 
vomiting  and  abdominal  distention,  one  cannot  help  but 
think  of  intestinal  obstruction. 

The  general  appearance  of  the  patient  changes.  The 
skin  is  gray  in  hue,  and  becomes  wrinkled;  the  eyes  are 
sunken,  with  distant  stare,  and  the  nose  assumes  a 
pinched  appearance.  The  skin  hangs  in  loose  folds;  it 
is  dry  and  has  lost  its  elasticity  so  that  it  may  be  picked 
up  into  ridges  which  remain  an  appreciable  interval  be- 
fore flattening  out.  The  lips  are  dry,  parched  and  often 
of  a  peculiar,  cherry  red  color.  The  mouth  is  held  partly 
open,  the  tongue  is  dry. 


264  INFANT  FEEDING. 

Nervous  symptoms  and  psychic  disturbances  are  usu- 
ally pronounced,  and  often  lead  to  a  confusion  with 
meningitis.  The  infant  is  restless;  the  sensorium  is  dis- 
turbed, with  an  occasional  cry  as  if  in  pain.  Before 
these  more  severe  symptoms  develop,  the  child  appears 
apathetic,  drowsy,  and  dopy.  The  face  assumes  a  fixed 
expression,  and  there  is  a  tendency  on  the  part  of  the  in- 
fant to  lie  constantly  in  one  position,  and  when  the  child 
moves  its  extremities  it  does  so  slowly,  as  if  too  tired  or 
weak  to  change  its  position.  The  arms  are  not  infre- 
quently flexed  in  an  attitude  resembling  that  of  a  prize 
fighter.  If  the  condition  increases  in  severity,  stupor  and 
coma,  associated  with  twitchings,  convulsions,  strabismus, 
and  other  meningeal  symptoms,  ensue. 

The  respiratory  manifestations  may  vary  from  a  slight 
increase  in  number  and  depth  to  a  marked  dyspnea.  The 
respirations  are  often  of  the  "air  hunger"  type,  such  as 
is  observed  in  diabetic  or  uremic  coma  (deep,  rapid  and 
without  pause).  The  breathing  becomes  both  costal  and 
abdominal,  the  whole  thorax  rises  with  each  inspiration 
and  accessory  muscles  are  brought  into  play.  This  is 
due  to  acidosis,  which  is,  however,  not  the  result  of  an 
overproduction  of  acetone  bodies,  but,  as  demonstrated 
by  Rowland  and  Marriott,1  it  is  caused  by  a  failure  of 
the  kidneys  to  excrete  acid  phosphate  and  in  part  to  acids 
produced  in  the  tissues  as  a  result  of  diminished  oxida- 
tion due  to  the  deficient  blood  circulation. 

The  urine  is  small  in  amount,  even  to  anuria.  It  may 
contain  albumen  and  not  infrequently  casts.  The  kidneys 
become  functionally  inactive,  although  there  are  usually 
no  demonstrable  pathological  changes.  This  alteration 
in  the  functional  capacity  of  the  kidney  results  in  the 
accumulation  in  the  blood  of  products  ordinarily  elimi- 
nated by  the  urine.  Uremic  symptoms  are  not  infre- 
quent as  a  result.  Occasionally  glycosuria  is  present. 

1  Rowland  and  Marriott :  Am.  Tour.  Dis.  of  Children;  11, 
309,  March,  1916. 


ANHYDREMIA.  265 

Schloss1  found  the  sugar  in  the  urine  to  be  either  glu- 
cose alone  or  glucose  in  combination  with  galactose  or 
lactose.  A  certain  amount  of  lactose  can  pass  through 
the  intestinal  mucosae  and  it  may  well  be  the  case  that 
when  fairly  strong  solutions  of  lactose  are  introduced 
into  the  intestinal  tract  of  these  infants  that  some  would 
be  absorbed  unchanged.  As  lactose  is  not  altered  out- 
side of  the  intestine,  it  would  be  excreted  quantitatively 
in  the  urine.  It  has  been  shown  by  Araki2  that  as- 
phyxial  conditions  occurring  as  the  result  of  vasocon- 
striction,  hemorrhage,  or  a  diminution  of  the  oxygen 
carrying  capacity  of  the  blood,  lead  to  glycosuria.  This 
is  generally  supposed  to  be  the  result  of  increased  glyco- 
genolysis,  dependent  upon  acid  production  in  the  tissues. 
In  the  case  of  these  infants  the  glycosuria  may  be  readily 
explained  on  the  same  basis.3  Schloss  has  demonstrated 
an  excess  of  urea  and  total  non-protein  nitrogen  in  the 
blood,  reduced  phenolsulphonephthalein  excretion  in  the 
urine  and  an  abnormally  high  Ambard  co-efficient  as 
evidence  of  impairment  of  renal  functions.  He  also 
found  that  the  extent  of  renal  function  involvement 
was  proportionate  to  the  degree  of  desiccation  of  the 
blood. 

The  Heart:  Action  is  weak  and  the  pulse  is  small, 
often  rapid  and  irregular. 

The  Blood  presents  changes  which  are  characteristic 
and  constant,  varying  only  in  degree.  The  changes  are 
dependent  upon  the  severity  of  the  case.  In  the  severer 
cases  the  blood  is  obtained  with  difficulty  due  to  the 
fact  that  it  is  thick  and  does  not  flow  easily,  and  when 
centrifuged  separates  a  relatively  small  amount  of  serum. 
These  findings  are  due  to  the  fact  that  it  is  concentrated 
by  water  loss.  The  specific  gravity  is  increased,  as  is 

1  Schloss,  O. :  Am.  Jour.  Dis.  of  Children,  xv,  165,  1918. 

2  Araki :  Ztschr.    Physiol.  Chem.,    Series   of  articles  in    15,   16, 
17,  19. 

3  Marriott:  Am.  Jour.  Dis.  of  Children,  xx,  461,  1920. 


266  INFANT  FEEDING. 

also  the  index  of  refraction.  There  is  a  negative  nitro- 
gen and  salt  balance.  The  viscosity,  the  electrical  con- 
ductivity and  the  osmotic  pressure  are  all  increased.  The 
state  of  uremia,  so  frequently  seen  in  the  fatal  cases, 
may  be  a  direct  result  of  the  increased  colloidal  osmotic 
pressure  of  the  blood  over  the  arterial  pressure  in  the 
renal  glomeruli,  which  results  in  decreased  secretion  of 
urine  by  the  kidneys.  Diminished  blood  volume  results 
in  a  greatly  diminished  volume  flow  of  the  blood.  There- 
fore, less  blood  flows  through  a  given  portion  of  the 
body  in  a  unit  of  time.  This  leads  to  an  accumulation 
of  acid  products  of  metabolism  in  the  tissues  and  a  de- 
creased alkali  reserve  of  the  blood,  that  is  to  say,  acid- 
osis.  The  blood  flow  in  the  arms  of  normal  infants, 
measured  by  the  Stewart  method,  by  Marriott,  ranged 
from  15  to  22  mils  per  100  Gm.  per  minute.  In  some 
infants  suffering  from  anhydremia  he  found  it  as  low 
as  2  or  3  mils  per  minute.  The  blood  pressure  is  usually 
maintained  through  the  high  blood  viscosity.  A  com- 
parison of  the  red  blood  cell  counts,  made  on  venous  and 
capillary  bloods,  shows  a  marked  concentration  of  cor- 
puscles in  the  capillaries.  This  stagnation  of  red  blood 
cells  in  the  capillaries,  as  the  result  of  arteriolar  con- 
striction, may  explain  the  peculiar  gray  pallor  of  the 
skin,  which  tends  to  disappear  with  the  establishment  of 
a  normal  circulation.  The  leucocytosis,  which  is  almost 
invariably  present,  may  in  part,  at  least  in  the  uncom- 
plicated cases,  be  due  to  a  damming  back  of  the  leuco- 
cytes in  the  capillary  blood.  In  those  complicated  by 
infection  a  higher  count  is  often  seen,  ranging  from  15 
to  35. 

Sclerema  is  present  in  the  severer  types — a  very  bad 
sign — due  to  a  coagulation  of  tissue  fluids  of  an  unknown 
nature. 

Enlargement  of  the  liver  accompanies  the  severe  types. 

Pathogenesis.  As  has  been  stated,  a  great  deal  of 
thought  has  been  given  to  the  clinical  picture  which  has 


ANHYDREMIA.  267 

been  described,  both  in  American  and  European  clinics. 
There  has  been  a  considerable  difference  of  opinion  as 
to  the  underlying  factors  influencing  the  train  of  symp- 
toms. In  the  well-developed  case  a  large  number  of 
symptoms  are  regularly  and  coincidentally  present  and 
it  has  been  the  object  of  the  various  clinicians  to  find 
an  adequate  explanation  for  all  of  the  symptoms.  The 
clinical  picture  in  those  infants  who  have  lapsed  into 
a  toxic  condition  following  severe  diarrhea  may  be  ex- 
plained on  the  basis  of  the  water  and  salt  losses  from 
the  body.  In  all  probability  there  is  also  a  deep-seated 
change  in  the  water  binding  functions  as  a  result  of  the 
loss  of  salts  and  the  breaking  down  of  glycogen  neces- 
sary to  meet  the  metabolic  functions  during  the  period 
of  under- feeding.  Unfortunately,  this  increased  water 
and  alkali  loss  by  the  intestines  is  not  balanced  by  les- 
sened kidney  secretion  until  the  renal  function  itself  is 
impaired  through  circulatory  disturbances.  There  is  also 
an  increased  water  loss  through  the  lungs  and  tempo- 
rarily at  least  in  the  presence  of  fever,  through  the  skin. 
Once  anhydremia  has  occurred  "a  vicious  circle"  is  es- 
tablished which  still  further  results  in  lowering  the  func- 
tional capacity  of  the  gastro-intestinal  tract.  Even  in 
the  absence  of  diarrhea  there  is  an  interference  with  the 
functional  capacity  of  the  intestines,  with  a  resulting 
increased  decomposition  of  food,  the  products  of  which 
may  cause  further  injury  to  the  intestine  itself.  Follow- 
ing this  there  may  be  an  absorption  of  bacterial  poisons 
from  the  intestines  which  may  result  in  a  toxic  catas- 
trophe. When  diarrhea  is  present  the  administration  of 
food  has  a  tendency  first  to  irritate  the  intestine,  more 
especially  when  hypertonic  sugar  solutions  are  adminis- 
tered ;  salts,  fats  and  proteins  may  have  a  similar  action. 
The  absorption  of  the  soluble  metabolites,  by  their  ac- 
cumulation in  the  blood,  increases  its  osmotic  pressure 
and  thereby  decreases  the  available  water  reserve.  Mar- 
riott believes  that  these  facts  are  an  adequate  explana- 


268  INFANT  FEEDING. 

tion  of  Finkelstein's  observation,  that  the  giving  of  food 
increased  the  symptoms  of  his  infants  suffering  from 
alimentary  intoxication.  It  is  quite  likely  that  interfer- 
ence with  the  function  of  the  liver  becomes  an  important 
factor  and  the  absorption  of  its  by-products  may  aggra- 
vate the  fever  and  diarrhea. 

The  secondary  picture  of  acidosis  may  be  superim- 
posed upon  that  of  anhydremia  with  clinical  evidence  of 
an  intoxication.  The  acidosis  in  these  cases  is  due  to  a 
deficient  renal  function  secondary  to  the  impaired  cir- 
culation through  the  kidneys  and  results  in  an  accumula- 
tion of  acid  phosphates  in  the  blood.  A  second  factor 
may  be  active  in  the  development  of  the  acidosis,  in  that 
there  is  a  tendency  toward  accumulation  of  lactic  acid 
in  the  tissues  from  partial  cell  asphyxia  which  is  also 
dependent  upon  the  diminished  blood  flow  secondary  to 
a  diminished  blood  volume.  Uremia  may  be  super- 
imposed in  this  stage.  The  state  of  acidosis  is  respon- 
sible for  the  "air  hunger"  type  of  respiration. 

Marriott  and  Perkins  made  a  series  of  investigations 
to  ascertain  the  presence  of  a  negative  water  balance  in 
two  groups  of  cases,  the  first  unassociated  with  diarrhea 
and  the  second  with  diarrheal  disturbances,  to  prove  that 
the  symptoms  in  both  groups  were  associated  with  simi- 
lar blood  findings.  As  a  criterion  of  the  degree  of  desic- 
cation of  the  body  fluids  they  determined  the  index  of 
refraction  of  the  blood  serum.  This  determination  is 
easily  made  and  requires  only  one  or  two  drops  of  serum. 
It  has  the  advantage  that  it  may  be  repeated  at  frequent 
intervals.  The  refractive  index  varies  with  the  concen- 
tration of  solids  in  solution.  As  the  protein  has  much 
greater  effect  on  the  index  than  the  other  solid  constitu- 
ents of  the  serum,  it  is  possible  to  determine  quite  ac- 
curately the  protein  content  of  the  serum  by  means  of 
tne  refractometer.  The  protein  content  of  the  serum 
of  normal  infants  during  the  first  six  months  of  life 
averages  about  6  per  cent. — toward  the  end  of  the  first 


ANHYDREMIA.  269 

year  it  is  often  as  high  as  7  per  cent.  1  2  Marriott  and 
Perkins-'5  observed  an  increase  in  the  protein  content  of 
the  serum  of  as  great  as  50  per  cent,  above  the  normal 
for  the  age.  They  were  able  to  demonstrate  a  state  of 
anhydremia  in  conditions  unrelated  to  diarrhea,  such  as 
pneumonia,  otitis,  pyelitis  and  non-infectious  conditions 
in  which  food  is  refused,  as  well  as  in  diarrheal  disturb- 
ances. 

Pathology.  In  the  small  intestine  there  is  usually 
no  marked  change.  Hyperemia  of  the  mucous  mem- 
brane and  enlarged  follicles,  especially  Peyer's  patches, 
are  usually  present.  The  liver  and  kidneys  show  a  hy- 
peremia,  cloudy  swelling,  and  fatty  degeneration  (prob- 
ably causing  hepatic  and  renal  insufficiency).  Other 
tissue  changes  which  may  be  present  are  not  specific  but 
such  as  might  be  expected  from  similar  noxae  acting  at 
any  time. 

Diagnosis.  The  diagnosis  is  based  on  the  above 
symptoms,  and  improvement  on  withdrawal  of  food, 
in  the  presence  of  a  sufficient  water  administration  by 
mouth,  subcutaneously,  intravenously  or  intraperitoneally. 
The  most  characteristic  and  striking  symptoms  are  those 
of  the  nervous  system  resulting  in  stupor,  pauseless  res- 
pirations, and  a  toxic  appearance.  These  are  usually 
associated  with  diarrhea,  vomiting  and  a  rapid  loss  in 
weight.  The  history  of  preceding  nutritional  disturb- 
ances and  infections  are  of  great  importance  in  diagnosis. 

Prognosis.  The  prognosis  in  anhydremia  depends 
upon  the  underlying  causes,  the  degree  of  desiccation 
and  the  previous  nutritional  condition  of  the  infant. 
When  anhydremia  is  due  simply  to  insufficient  fluid  in- 
take it  usually  clears  promptly  after  a  sufficient  amount 
of  water  has  been  taken  by  mouth.  Anhydremia  re- 
sultant from  diarrhea  or  the  combination  of  vomiting 

iReiss:  Jahrb.  f.  Kinderh.,  Ixx,  311,  1909.  Ergeb.  d.  Inn.  Med. 
u.  Kinderh.,  x,  531,  1913. 

2Salge:  Ztschr.  f.  Kinderh.,  1911,  pp.  126,  317. 
3  Personal  communication. 


270  INFANT  FEEDING. 

.  and  diarrhea  is  more  serious  than  that  due  to  other 
causes.  The  prognosis  is  especially  bad  in  the  case  of 
infants  already  athreptic.  The  presence  of  acidosis  ren- 
ders the  prognosis  exceedingly  grave,  not  so  much  on 
account  of  the  acidosis  itself,  for  that  can  be  cured,  but 
because  the  presence  of  acidosis  indicates  that  extreme 
desiccation  has  occurred,  with  profound  disturbance  of 
the  metabolism. 

As  infections,  both  parenteral  and  enteral,  are  com- 
monly the  underlying  causative  factor,  the  further  dan- 
gers from  this  source  must  not  be  under-estimated  and 
further  treatment  must  be  directed  to  their  relief.  The 
prognosis  is  also  directly  dependent  upon  the  ability  of 
the  infant  to  retain  a  sustaining  diet  after  the  subsidence 
of  the  acute  toxic  symptoms.  The  younger  the  infant, 
the  more  difficult  will  be  the  problem  unless  breast  milk 
be  available. 

Treatment.  In  the  presence  of  vomiting  and  diar- 
rhea, more  especially  when  they  are  complicated  by  an 
inability  to  retain  sufficient  inert  fluids,  every  effort 
should  be  made  early  in  their  treatment  to  prevent  the 
development  of  anhydremia.  Vomiting  and  diarrhea 
are  to  be  treated  as  previously  recommended.  (Page 
230). 

All  food  should  be  withdrawn  for  from  six  to  twelve 
hours  and  in  some  cases  as  long  as  twenty-four  hours. 

Sufficient  water  must  be  administered  to  overcome  the 
loss  from  all  causes.  The  average  infant,  in  the  pres- 
ence of  vomiting,  diarrhea  and  fever,  will  require  a 
minimum  of  one-fifth  of  its  body  weight  in  water  in 
twenty-four  hours.  In  order  to  estimate  the  amount 
administered,  a  careful  record  must  be  kept  of  the 
amounts  given  and  retained. 

As  much  as  possible  should  be  given  by  month  in  small 
feedings  at  frequent  intervals.  Water  given  immediately 
after  vomiting  is  frequently  retained. 


ANHYDREMIA.  271 

A  single  gastric  lavage  is  indicated  if  food  has  been 
given  shortly  before  or  in  the  presence  of  repeated 
vomiting. 

In  severe  types  subcutaneous  injection  of  saline  solu- 
tions, two  or  more  times  daily,  are  indicated,  100  to  300 
mils  can  be  injected  each  time.  Ringer's  solution  may 
be  used  to  advantage  for  this  purpose. 

Gm.  or  Mil. 

NaCl 7.5 

KC1 0.1 

CaCl  0.2 

Water 1000.0 

The  water  used  in  making  this  solution  should  be  re- 
distilled shortly  before  using. 

The  same  solution  may  be  administered  intravenously 
in  young  infants  through  the  longitudinal  sinus  and  in 
older  infants  into  the  anterior  jugular  or  median  basilic 
vein.  It  should,  however,  be  remembered  that  there  is 
danger  of  collapse  from  acute  cardiac  dilatation  when 
excessive  amounts  are  introduced  rapidly  into  the  circu- 
latory system.  On  the  average  an  amount  not  to  exceed 
%0  of  the  body  weight  should  be  injected  at  one  time. 
The  gravity  method  should  be  used.  The  danger  of  ad- 
ministering fluids  by  way  of  the  longitudinal  sinus  must 
be  appreciated. 

Probably  the  most  efficient  means  of  introducing  water 
into  infants  of  this  type  is  by  way  of  the  peritoneal 
cavity.  This  method  of  administration  was  first  used 
extensively  in  this  country  by  Rowland,1  after  seeing 
its  successful  application  by  Garrod,  in  London. 

Large  amounts  of  fluid  may  be  given  this  way  and  be 
rapidly  and  completely  absorbed.  Ringer's  solution  is 
the  best  for  this  purpose,  and  should  be  freshly  sterilized 
before  using.  The  injection  is  easily  given  and  causes 
very  little  pain  or  discomfort.  The  needle  used  for  the 


1  Blackfan,  K.  D.  and  Marcy,  K.  F. :  Am.  Jour.  Dis.  of  Chil- 
dren, vol.  xv,  19,  1918. 


272  INFANT  FEEDING. 

injection  should  not  be  very  sharp.  A  suitable  size  is 
18  gauge,  which  is  about  the  size  commonly  used  for 
serum  injections.  Strict  aseptic  technique  is  absolutely 
essential.  There  is  but  little  danger  of  puncturing  the 
intestine,  if  the  method  described  is  carefully  followed. 
This  route  of  fluid  administration  should  not  be  under- 
taken unless  all  details  can  be  fulfilled. 

The  technique  is  as  follows:  If  abdominal  distention 
is  present,  this  must  first  be  relieved.  The  patient  lies 
in  the  recumbent  posture,  with  the  movements  of  arms 
and  legs  restricted  by  a  restraining  jacket.  The  most 
favorable  site  for  the  introduction  of  the  needle  is 
through  the  linea  alba,  just  below  the  umbilicus.  The 
skin  is  prepared  after  the  usual  surgical  method,  with 
iodin  and  alcohol,  and  the  area  may  be  rendered  anes- 
thetic with  ethyl  chlorid.  The  solution  is  introduced  by 
gravity  from  an  infusion  bottle,  only  slightly  elevated. 
It  should  be  introduced  at  about  100°  F.  When  the 
patient  is  restrained  in  the  proper  position  and  the  site 
for  the  injection  prepared,  the  skin  and  subcutaneous 
tissues  are  picked  up  between  the  thumb  and  the  index 
finger,  and  the  needle,  pointing  upward,  is  inserted  at 
an  oblique  angle.  After  it  has  penetrated  the  peritoneum 
the  fluid  is  allowed  to  flow  into  the  peritoneal  cavity. 

The  injection  of  the  fluid  is  continued  until  the  abdo- 
men becomes  slightly  distended.  It  should  not  be  in- 
troduced too  rapidly  or  in  too  large  quantities,  to  avoid 
the  possibility  of  embarrassing  the  respiratory  and  cir- 
culatory systems.  Two  hundred  to  500  mils  can  be  in- 
troduced in  from  fifteen  to  twenty  minutes.  After  the 
fluid  has  been  introduced,  the  needle  is  withdrawn  and 
the  puncture  wound  covered  with  a  sterile  dressing.  The 
injection  may  be  repeated  after  six  to  twelve  hours,  if 
necessary.  With  repeated  injections,  even  with  an  iso- 
tonic  solution,  there  develops  an  edema  of  the  peritoneum 
and  frequently  some  exudate.  This  disappears  without 
untoward  effect.  However,  with  the  use  of  hypertonic 


ANHYDREMIA.  273 

solutions  more  serious  injury  of  the  peritoneum  may 
result.  \Ye  have  therefore  discontinued  the  use  of  glu- 
cose and  bicarbonate  of  soda  in  the  solution. 

If  the  infant  presents  evidence  of  acidosis,  dextrose 
should  be  added  to  the  saline  solutions  and  administered 
intravenously.  Six  Gm.  (90  gr.)  of  dextrose  may  be 
added  to  120  mils  (4  ounces)  of  saline  solution  and  re- 
peated in  four  to  six  hours,  if  indicated.  Pure  dextrose 
is  essential.  Only  rarely  is  there  an  indication  for  the 
administration  of  alkali.  It  should  be  remembered  that 
intravenous  administration  of  larger  amounts  of  sodium 
bicarbonate  may  result  in  collapse.  (See  Acidosis.) 

Saline  per  rectum  is  best  administered  by  the  drop 
method  unless  the  infants  are  too  restless.  Thirty  drops 
per  minute  for  four  hours  is  450  mils.  One-half 
strength  of  Ringer's  solution  may  be  used.  Sodium  bi- 
carbonate, 5.0  Gm.  (75  grs.)  may  be  added  to  every  500 
mils  of  the  solution  (1  per  cent.). 

It  is  necessary  that  sufficient  administration  of  water 
be  continued  until  the  causative  factor  of  the  anhydremia 
is  no  longer  operative.  The  initial  loss  in  these  infants 
may  reach  amounts  approximating  1000  to  2000  grams. 

The  treatment  must  also  be  directed  to  the  over- 
coming of  any  infectious  processes  which  may  be  pres- 
ent. It  is  to  be  rememberd  that  the  severe  forms  en- 
countered are  often  seen  in  infants  who  have  suffered 
from  repeated  attacks  of  nutritional  disturbances,  and 
that  in  the  presence  of  athrepsia  the  convalescence  must 
necessarily  be  slow.  All  laxatives  are  to  be  avoided  in 
the  presence  of  marked  diarrhea,  as  the  bowels  empty 
themselves  and  any  further  purgation  increases  the  loss 
of  salts  and  water  and  the  tendency  to  the  development 
of  an  acidosis. 

Opium  is  indicated  when  the  stools  are  frequent,  large 
and  watery,  and  remain  uncontrolled  by  other  methods. 
Paregoric  in  suitable  doses  per  mouth,  or  the  tincture 
per  rectum,  may  be  used  with  care. 

18 


274  INFANT  FEEDING. 

Analeptics.  Give  a  mustard  bath  in  case  of  collapse. 
Reddening  of  the  skin  is  a  good  sign. 

Antipyretics.  Use  tepid  packs,  and  leave  the  infant 
undressed.  Ice-cap  to  head  is  useful,  but  should  not  be 
applied  directly  to  the  head,  because  of  the  thinness  of 
the  skull  in  young  infants. 

Stimulants.  In  collapse,  warm  packs  or  baths  are  in- 
dicated. Caffein  sodium  benzoate,  0.006  Gm.  to  0.030 
Gm.  (0.1  to  0.5  gr.),  four  or  five  times  daily;  camphor- 
ated oil  in  1-mil  doses  every  two  hours  hypodermically 
if  indicated;  epinephrin  solution,  0.2  to 0.3  mil  (1  to  1000), 
subcutaneously  or  intravenously. 

Sedatives  for  Convulsions.  Sodium  bromide,  0.2  Gm. 
to  0.3  Gm.  (3  to  5  gr.),  repeated  in  three  to  four  hours; 
veronal,  0.05  Gm.  (1  gr.).  Chloral  hydrate  is  best 
avoided. 

An  electric  fan  is  a  most  valuable  addition  to  our 
therapeutic  measures  in  summer. 

Lumbar  puncture  may  be  indicated  in  the  presence  of 
increased  intracranial  pressure,  and  for  diagnostic  pur- 
poses. 

Diet.  Hunger  diet  should  be  employed  rarely  longer 
than  twenty-four  hours.  When  infant  is  stuporotis, 
water  should  be  administered  by  gavage  at  regular  inter- 
vals of  about  three  to  four  hours. 

In  cases  of  food  intoxication,  twenty-four  hours  on  a 
hunger  diet,  with  sufficient  water,  causes  striking  changes. 
The  child  looks  bright,  smiles,  and  to  all  appearances 
looks  convalescing,  notwithstanding  a  usual  loss  of 
weight.  The  stools  also  become  less  frequent,  and  al- 
though small  and  containing  mucus  (hunger  stools), 
they  cause  less  irritation  of  the  buttocks  and  little  loss 
of  water.  The  improvement  is  no  less  striking  than 
that  seen  in  the  crisis  of  pneumonia. 

Human  Milk.  Human  milk  is,  by  all  means,  the  best 
food.  Feed  often,  and  in  small  amounts,  ten  times  daily, 
five  mils  from  bottle  or  spoon.  The  infant  may  also  be 


ANHYDREMIA.  275 

placed  directly  at  breast  for  one-  or  two-minute  periods, 
in  less  severe  cases.  Increase  when  the  temperature, 
etc.,  does  not  react  to  food,  and  then  not  more  than  50 
to  100  mils  daily  increase  at  first.  After  several  days, 
if  the  infant  shows  no  evidence  of  relapse,  it  is  again 
placed  unrestrictedly  on  the  breast.  If  this  is  done  too 
soon,  relapses  occur.  A  too  prolonged  starvation  adds 
the  danger  of  inanition. 

A  sustaining  diet  should  be  reached  in  eight  to  ten 
days  (70  calories  per  kilo),  after  which  the  child  can  be 
put  on  the  breast  five  times  daily.  Weigh  infant  be- 
fore and  after  feeding,  if  placed  at  breast.  The  gain  in 
weight  is  often  slow  in  the  stage  of  repair  on  human 
milk,  due  to  the  low  protein  and  salt  content. 

Coitfs  Milk.  The  feeding  of  these  infants,  for  whose 
use  breast  milk  is  not  available,  should  follow  the 
same  principles  as  outlined  for  the  treatment  of  diarrhea. 
(See  page  231.)  It  must,  however,  be  remembered  that 
even  greater  care  is  needed  because  of  a  tendency  to 
recurrence  of  acute  diarrheal  attacks.  In  every  case 
where  there  is  a  second  recurrence  of  toxic  symptoms, 
breast  milk  is  absolutely  indicated.  These  infants  do 
best  when  they  are  fed  with  small  quantities — 10  or  15 
mils — repeated  at  short  intervals,  with  the  administration 
of  eight  or  ten  feedings  daily.  This  holds  true  with  the 
feedings  of  albumin  milk,  as  well  as  with  the  fat-free 
lactic  acid  and  skim  milk  plus  gruel  mixtures.  At  all 
times  the  water  administration  should  be  held  at  the 
maximum.  For  the  first  few  days  after  the  hunger  day, 
a  food  low  in  fat  and  sugar  should  be  fed.  Even  on 
this  low  diet  weight  loss  usually  stops  but  this  should 
not  lead  to  an  underestimation  of  the  great  danger  from 
a  too  prolonged  under-feeding.  These  infants  offer  every 
indication  for  the  use  of  our  best  judgment. 


CHAPTER  VII. 
INFECTION   AND    NUTRITION. 

THE  intimate  relation  between  infection  and  nutrition 
may  be  made  clear  by  considering  the  subject  under  three 
headings : 

1.  The    susceptibility   to   infections   as   influenced   by 
previous  diet  and  the  state  of  nutrition. 

2.  The  course  of  infections  as  affected  by  diet  and  the 
state  of  nutrition. 

3.  The  influence  of  infection  upon  nutritional  proc- 
esses. 

(a)   Parenteral  infections. 
(&)  Enteral  infections. 

1.  Susceptibility  Influenced  by  Nutrition. 

The  previous  diet  and  the  state  of  nutrition  being  the 
same,  there  are  marked  individual  differences  in  the  sus- 
ceptibility to  infection.  Among  the  breast-fed  infants 
there  are  on  one  hand  infants  who  remain  free  from  any 
infection,  even  under  very  unfavorable  external  condi- 
tions, while  on  the  other  hand  there  are  breast-fed  infants 
who  under  favorable  conditions  often  contract  an  infec- 
tion. This  points  to  congenital  differences  based  on  the 
difference  in  the  constitution  of  the  individual.  As  a 
rule,  the  lowering  of  immunity  is  not  the  only  sign  of 
inferior  constitution  in  these  infants,  but  they  show  a 
number  of  other  symptoms  of  a  constitutional  anomaly, 
such  as  exudative  and  neuropathic  diathesis.  In  this 
group  of  infants  the  susceptibility  to  infection  becomes 
even  more  striking  when  they  are  put  on  artificial  feeding, 
and  especially  when  the  diet  is  improper.  In  infants 
with  constitutional  anomalies  one  is  justified  in  thinking 
of  an  abnormal  composition  of  the  tissues  and  of  the 
(276) 


INFECTION   AND   NUTRITION.  277 

body  fluids,  both  the  latter  factors  in  themselves  leading 
to  a  lowering  of  immunity. 

The  natural  immunity  of  the  healthy  breast-fed  infant 
affords  the  best  example  of  the  importance  of  the  diet 
in  the  establishment  of  resistance  to  infection. 

In  the  artificially  fed  infants  the  increased  susceptibil- 
ity to  infection  is  usually  based  on  nutritional  disturb- 
ances, which,  however,  may  be  so  slight  as  to  escape 
recognition.  However,  when  a  careful  study  is  made 
of  the  feeding  history  the  cause  can  usually  be  demon- 
strated in  a  poorly  balanced  diet,  more  commonly  one 
excessive  in  carbohydrates  and  fats,  which  result  in  an 
abnormal  composition  of  the  tissues  (see  Nutritional 
Disturbances).  Those  modes  of  feeding  which  cause 
normal  tissue  chemistry  diminish  susceptibility,  while 
every  form  of  feeding  which  unfavorably  influences 
metabolism  increases  susceptibility  to  infection. 

In  artificially  fed  infants  these  facts  offer  valuable 
therapeutic  suggestions,  and  should  lead  one  to  avoid 
overfeeding  as  a  whole  as  well  as  of  the  individual  con- 
stituents of  the  diet,  and  the  early  administration  of  the 
mixed  diet. 

The  susceptibility  to  infection  is  increased  by  every 
nutritional  disturbance.  This  applies  to  the  simple  and 
seemingly  harmless  digestive  disturbances,  as  well  as  to 
the  more  severe  forms.  (Athrepsia,  anhydremia.) 

2.  Course  of  Infections  Influenced  by  Nutrition. 

The  course  of  the  infection  is  essentially  influenced  by 
constitution,  age,  hygienic  conditions,  mode  of  feeding, 
and  the  state  of  nutrition.  The  premature  and  the  very 
young  react  poorly  to  infections.  Gastro-intestinal,  pul- 
monary and  septic  infections  of  the  newborn  have  usu- 
ally an  unfavorable  course,  especially  in  the  artificially 
fed  infants.  Infants  suffering  from  constitutional  anom- 
alies are  less  likely  to  react  favorably  than  normal, 
healthy  infants.  In  all  infants  suffering  from  exudative 


278  INFANT   FEEDING.    . 

or  neuropathic  diathesis  even  slight  infections  should  be 
given  serious  consideration. 

Nutritional  disturbances  have  a  direct  influence  on  the 
prognosis  of  all  forms  of  infections.  This  is  more  espe- 
cially true  of  the  infections  of  the  respiratory  passages, 
in  which  a  simple  rhinitis  or  pharyngitis  may  readily  be 
complicated  by  pneumonia  and  severe  gastro-intestinal 
complications,  but  also  true  of  the  simple  skin  infections, 
which  may  rapidly  take  a  serious  course  resulting  in 
sepsis. 

The  institution  of  a  proper  diet  is  of  primary  impor- 
tance in  all  cases  of  infections. 

Feeding  with  human  milk  is  the  treatment  of  choice. 
If  this  is  not  obtainable,  and  it  is  necessary  to  feed  arti- 
ficial food  mixtures,  they  must  of  necessity  be  well  bal- 
anced, and  one-sided  carbohydrate  diets  are  to  be  avoided. 
Whenever  possible,  a  mixed  diet  should  be  instituted. 

3.  Infection  Influencing  Nutrition. 

Infection  may  produce  any  form  of  nutritional  dis- 
turbance, from  the  slightest  forms  to  the  most  severe 
forms  of  athrepsia  and  anhydremia.  For  the  production 
of  nutritional  disturbances,  infections  are  to  be  ranked  as 
of  equal  importance  with  dietetic  errors. 

Although  the  course  of  alimentary  nutritional  disturb- 
ances may  be  similar  to  that  of  nutritional  disturbances 
due  to  infection,  still  there  are  important  differences  that 
must  be  kept  constantly  in  mind  in  order  to  avoid  fail- 
ures in  the  treatment.  The  following  table  briefly  sum- 
marizes the  most  important  differences  between  the  two 
forms  of  nutritional  disturbances: 

Nutritional    Disturbances    due   to  Nutritional    Disturbances    due   to 

Alimentation.  Infection. 

History  of  dietetic  errors,  espe-  Acute  disturbances  not  so 
cially  high  sugar  and  fat  much  dependent  on  the 
feedings  or  underfeeding.  nature  of  the  diet. 


INFECTION   AND   NUTRITION.  279 

Nutritional    Disturbances   due   to  Nutritional    Disturbances   due   to 

Alimentation.  Infection. 

Disintoxication  of  toxic  states      Toxic  states  continue  or  even 
(fever,    nervous     symptoms,          become    worse    in    spite    of 
etc.)  by  withdrawal  of  food,          withdrawal  of  food, 
and  administration  of  suffici- 
ent water. 

Improvement   in   general   con-      Persistence    of   diarrhea   after 
dition,  and  especially  of  diar-          similar    change    of    diet,    at 
rhea,    on    correction    of   the          least.in  a  number  of  cases, 
diet,  especially  by  reduction 
of  fat,  whey  and  sugar  com- 
ponent part. 

Progressive  narrowing  of  food      Spontaneous  increase  of  toler- 
tolerance  in  untreated  cases.          ance  without  special  dietetic 

treatment  after  the  infection 
passes  over  (in  majority  of 
cases,  not  always). 

(A)  Parenteral  Infections. 

Etiology.  It  has  already  been  pointed  out  with 
what  great  frequency  infants  and  children  suffering  from 
nutritional  disturbances  are  subject  to  secondary  infec- 
tion. The  most  frequent  of  these  are  those  of  the  skin, 
respiratory,  gastro-intestinal,  and  genito-urinary  tracts, 
ears  and  general  septic  infections. 

In  contradistinction  to  this,  infections,  such  as  "colds," 
tonsillitis,  pneumonia,  otitis,  cystitis,  pyelitis,  which  are 
accompanied  by  lowered  food  tolerance,  are  accompanied 
by  diarrheas.  They  are  likely  to  run  a  more  severe  course 
than  the  primary  nutritional  disturbances. 

Undoubtedly  many  cases  of  diarrheal  disturbances  in 
the  course  of  acute  infections  are  due  to  an  infection  of 
the  gastro-intestinal  tract  following  the  swallowing  of 
organisms  from  the  upper  respiratory  tract,  thereby  de- 
veloping a  secondary  enteral  infection. 

The  common  occurrence  of  the  "summer  diarrheas" 
leads  us  to  search  for  a  relationship  between  heat  and  the 
nutritional  disturbances  as  seen  in  summer.  This  rela- 


280  INFANT   FEEDING. 

tionship  has  already  been  discussed  under  the  chapter  on 
Anhydremia  Intoxication.  However,  it  may  be  well  to 
briefly  enumerate  the  factors  which  are  important  in  the 
causation  of  these  nutritional  disturbances.  High  tem- 
peratures cause  systemic  depression,  and  directly  influ- 
ence all  of  the  body  functions.  Less  food  is  required  in 
hot  weather,  and  therefore  the  previous  diet  may  be  con- 
sidered excessive  in  many  instances.  Bacterial  action  on 
the  milk,  and  the  subsequent  production  of  toxic  bodies, 
is  a  factor  of  primary  importance.  An  excessive  reten- 
tion of  heat  by  overdressing  during  the  summer  months 
has  been  proven  to  be  a  contributing  factor  by  McClure 
and  Sauer.1 

A  study  of  the  cases  of  diarrheas  in  the  wards  of 
Sarah  Morris  Hospital  by  Gerstley  and  Day  during  the 
course  of  two  summers  showed  that  most  of  our  intes- 
tinal cases  were  secondary  to  parenteral  infections,  and 
not  primary  intestinal  infections,  as  described  by  Ken- 
dall and  Day  in  their  investigations  of  the  Boston  epi- 
demics. This  could  in  greater  part  at  least  be  accounted 
for  by  the  fact  that  all  of  the  milk  fed  to  our  infants  was 
either  pasteurized  or  boiled,  while  in  the  eastern  cities 
considerable  raw  milk  was  fed. 

Symptoms.  By  careful  clinical  observation  and  ex- 
perimental investigation  we  know  that  infection  may 
produce  the  following  changes: 

1.  Lessening  the  gain   in   weight   without   any   acute 
symptoms  manifesting  in  the  gastro-intestinal  canal  dur- 
ing or  after  the  infection. 

2.  Loss   of    weight   and   changes   in   the   stools   cor- 
responding to  the  acute  nutritional  disturbances. 

(a)  Acute  disturbances  of  the  nature  of  diarrhea 
beginning  with  the  infection  and  disappear- 
ing after  the  infection  has  been  overcome. 

(&)  Acute  disturbances  which  begin  with  the  infec- 
tion, but  remain  even  after  the  infection  is 

i  Sauer :  Am.  Jour.  Dis.  of  Child.,  1915,  ix,  490. 


INFECTION  AND  NUTRITION.  281 

overcome,  under  certain  conditions  for  weeks 
(chronic  intestinal  indigestion), 
(c)  Grave  nutritional  disturbances  beginning  with 
the  infection,  but  soon  becoming  the  most 
prominent  factor  in  the  clinical  picture,  with 
or  without  toxic  symptoms. 

Diagnosis.  Anhydremic  intoxication  is  usually  easily 
recognized  by  the  nervous  symptoms,  toxic  expression, 
pauseless  respiration,  and  marked  drops  in  the  weight 
curve.  In  intoxication,  temporary  complete  withdrawal 
of  food  with  sufficient  water  administration  in  the  ab- 
sence of  severe  infection  results  in  disintoxication.  This 
is  known  as  therapeutic  dietetic  test.  In  parenteral  in- 
fections this  is  not  the  case,  and  starvation  only  leads  to 
further  reduction  of  resisting  power,  and  therefore  should 
not  be  long  continued. 

It  is  necessary  to  avoid  the  mistake  of  overestimating 
the  intestinal  condition  for  which  in  many  cases  the 
physician  is  called,  and  thereby  failure  to  recognize  the 
underlying  infection,  such  as  "cold,"  bronchitis,  pneu- 
monia, pyelitis,  etc.,  as  a  fundamental  factor. 

Treatment.  For  treatment  practically  the  most  im- 
portant characteristic  of  nutritional  disturbances  due  to 
infection  is  the  spontaneous  rise  of  food  tolerance  after 
the  cure  of  the  infection. 

The  primary  infection  calls  for  foremost  considera- 
tion, and  its  treatment  must  necessarily  vary  according 
to  its  nature.  The  intestinal  condition,  on  the  other  hand, 
if  mild  in  nature,  frequently  calls  for  little  treatment  in 
these  infants,  more  especially  because  in  the  presence  of 
fever  there  is  a  tendency  to  reduce  the  intake  of  food, 
which  in  itself  is  sufficient  to  correct  the  intestinal  dis- 
turbance. Further,  with  the  improvement  of  the  infec- 
tion the  appetite  returns,  and  the  infant  will  demand  in- 
creased food. 

Where  it  is  possible  to  keep  up  the  baby's  nutrition  by 
the  proper  administration  of  food  during  the  course  of  an 


282  INFANT  FEEDING. 

infection,  such  children  may  be  subject  to  little  or  no 
weight  loss.  In  more  serious  cases  the  food  must  be  re- 
duced both  qualitatively  and  quantitatively,  more  espe- 
cially the  sugars  and  the  fats.  However,  in  order  to 
avoid  catastrophes,  long-continued  underfeeding  or  star- 
vation must  of  necessity  be  avoided,  since  this  treatment, 
causing  insufficient  nutrition  of  the  body-cells,  would  de- 
crease the  resistance  of  the  infant.  Albumin  milk,  and 
skim  and  buttermilk  mixtures,  with  small  amount  of 
sugar  are  best  used.  Carbohydrates  should  be  added  as 
rapidly  as  the  infant's  condition  will  permit.  Prolonged 
carbohydrate  starvation  is  to  be  avoided,  more  especially 
in  the  presence  of  high  temperatures  and  acidosis.  They 
should  be  increased  gradually.  In  grave  nutritional  dis- 
turbances, with  sudden  losses  of  weight  and  toxic  sym- 
toms,  complete  withdrawal  of  food  cannot  be  avoided. 

In  young  and  weak  infants,  as  previously  stated,  breast 
milk  may  be  imperative.  In  older  infants,  and  those  less 
severely  infected,  albumin  milk,  with  2  or  3  per  cent,  of 
sugar  addition,  or  buttermilk  and  skim  milk  mixtures  are 
frequently  well  taken.  In  all  cases  inanition  must  be 
avoided  by  keeping  the  child  on  a  sustaining  diet  of  70 
calories  per  kilogram,  or  an  amount  above  this. 

The  type  of  infants  who  have  been  improperly  fed, 
more  especially  those  who  have  been  raised  on  con- 
densed milk  or  other  foods  containing  a  minimum  of 
fat  and  protein,  but  an  excess,  of  carbohydrates,  offer 
greater  difficulties,  because  they  possess  a  limited  im- 
munity to  all  forms  of  infection,  beside  reacting  poorly 
to  changes  in  their  diet  during  illness.  They  also  react 
very  poorly  to  starvation,  rapidly  passing  into  a  state  of 
decomposition.  The  treatment  in  these  cases  should  fol- 
low that  outlined  for  milder  forms  of  athrepsia. 

To  repeat,  under  all  circumstances  food  should  be  re- 
stricted as  little  as  possible. 


INFECTION   AND   NUTRITION. 


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284  INFANT  .FEEDING. 

The  two  most  important  symptoms  calling  for  treat- 
ment in  the  course  of  parenteral  infections  are  (1)  vomit- 
ing and  (2)  refusal  of  food. 

If  temporary  reduction  in  food  does  not  relieve  vomit- 
ing, it  may  be  necessary  to  resort  to  gastric  lavage  which 
is  best  performed  with  1  per  cent,  sodium  bicarbonate 
solution,  allowing  2  or  3  ounces  of  the  solution  to  re- 
main in  the  stomach,  with  the  administration  of  slightly 
sweetened  tea  or  cereal  waters  ad  libitum,  as  retained. 
Prolonged  starvation  must  be  avoided. 

We  have  found  chymogen  milk  fed  in  small  quantities 
at  two-  to  three-  hour  intervals  especially  suitable  for 
these  cases.  This  is  probably  due  to  the  fact  that  the 
casein  is  precipitated  in  a  flocculent  form. 

Refusal  of  food  which  is  commonly  experienced  in 
these  infants  calls  for  catheter  feeding  (see  chapter  on 
Methods  of  Feeding  Premature  Infants). 

(B)  Enteral  Infections. 

Etiology.  Besides  the  alimentary  nutritional  dis- 
turbances proper,  there  are  in  childhood,  and  especially 
in  infancy,  numerous  diseases  that  have  to  be  regarded 
as  true  infections  of  the  digestive  canal,  due  to  invasion 
of  pathogenic  bacteria,  or  increased  and  changed  activity 
of  the  bacteria  normally  present.  In  many  cases  infective 
material  is  introduced  by  food,  and  especially  by  the 
milk,  in  which  the  micro-organisms  are  present,  being  de- 
rived from  the  diseased  cattle  that  furnish  the  milk 
(Streptococcus  from  inflamed  udders,  Bacillus  coli  from 
feces)  or  bacteria  pathogenic  for  the  human  may  find 
their  way  into  the  milk  in  transportation  from  the  place 
of  production  to  the  place  of  consumption.  Besides  this, 
water  or  contaminated  foods  other  than  milk  may  be  the 
medium  through  which  infection  takes  place. 

There  are  numerous  cases  of  transmission  by  contact. 
These  are  most  commonly  seen  in  the  epidemic  appear- 


INFECTION   AND   NUTRITION.  285 

ance  of  gastro-enteritis  in  institutions  for  small  children 
and  infants.  A  small,  but  typical  epidemic  is  reported 
by  Smillie,1  who  had  observed  it  during  his  study  of  epi- 
demiology of  bacillary  dysentery.  Four  babies  developed 
bacillary  dysentery  in  the  wards  of  the  hospital,  each  of 
them  having  been  admitted  with  quite  a  different  diag- 
nosis, and  their  stools  having  been  negative  on  admis- 
sion. Each  developed  the  disease  seven  to  ten  days  after 
admission,  and  in  no  instance  did  the  infant  come  from 
an  infected  home  or  neighborhood.  Similar  epidemics 
are  experienced  in  all  institutions  caring  for  infants,  in 
which  aseptic  nursing  is  not  practiced. 

The  environment  of  the  infant,  and  especially  lack  of 
proper  cleanliness  generally,  and  in  preparation  of  food 
especially,  are  very  important  factors,  which  make  the 
enteral  infection  possible. 

Parenteral  infections  are  often  followed  by  enteral  in- 
fections, and  this  is  especially  true  of  infections  of  the 
respiratory  tract  which  often  lead  to  what  has  been  called 
' '  b  r  onchoenter  ocatar  rh . ' ' 

The  most  important  clinical  condition  among  the  en- 
teral infections  is  inflammation  of  the  intestinal  mucosa 
(enteritis),  brought  about  by  a  variety  of  bacteria,  and 
accompanied  by  slimy,  purulent,  and  bloody  evacuations 
and  tenesmus. 

The  causative  bacteria  may  be  organisms  normally 
present  in  the  intestinal  tract  which  in  the  presence  of 
an  environment  suitable  to  their  abnormal  growth,  be- 
come pathogenic  to  the  host,  or  the  offending  organism 
may  be  introduced  from  without  through  food  or  by 
contact  with  infected  excreta  or  other  matter. 

The  organisms  which  have  been  most  frequently  iso- 
lated from  the  intestinal  tract  during  the  more  recent 
epidemics  are  the  B.  paratyphosus  group,  of  which  the 
alpha  and  beta  types  are  probably  the  most  frequent  of- 


Smillie :  Am.  Jour.  Dis.  Child.,  1917,  xiii,  337. 


286  INFANT   FEEDING. 

fenders  in  paratyphoid  fever  in  the  young.  Both  of 
these  organisms  are  occasionally  found  in  the  intestinal 
contents  and  feces  of  children  who  give  no  history  of 
infection. 

The  various  types  of  B.  dysenterise  have  been  isolated 
in  numerous  severe  epidemics,  in  both  infants  and 
children. 

While  this  group  covers  a  considerable  number  of 
bacilli  showing  minor  morphological  and  cultural  dif- 
ferences, they  may,  however,  be  divided  into  two  main 
groups,  the  division  being  based  on  the  difference  in  their 
reaction  with  litmus  mannite.  The  first  group  is  known 
as  the  "true  Shiga,"  or  "alkaline  type";  the  second  as 
the  "acid  type,"  which  includes  the  organisms  which  have 
most  frequently  been  found  in  the  diarrheal  diseases  of 
infants  and  children  in  the  United  States.  This  second 
group  includes  the  Flexner-Harris,  the  "Y"  type  of  Hiss 
and  Russell,  and  the  Strong  subvarieties.  The  "Shiga" 
type  has  been  found  in  some  cases  alone  and  even  less 
frequently  it  has  been  isolated  in  cases  in  which  the 
"acid"  types  were  present.  Both  of  these  latter  findings 
have,  however,  been  the  exception  in  the  dysenteries  of 
children. 

B.  typhosus,  while  not  an  infrequent  cause  of  severe 
infectious  diarrhea  in  infancy  has  only  rarely  been  iden- 
tified as  the  specific  organism  in  generalized  epidemics. 

B.  coli  may  become  so  abundant  and  virulent  as  to  pro- 
duce severe  types  of  enteritis.  Streptococci  have  been 
reported  repeatedly  as  the  predominating  organism  in 
isolated  epidemics  of  severe  types  associated  with  deep 
intestinal  lesions. 

The  role  of  B.  aerogenes  capsulatus  (gas  bacillus  of 
Welch)  as  a  specific  factor  in  epidemics  is  still  in  dis- 
pute. It  has  been  isolated  in  large  numbers  and  was  a 
constant  finding  in  several  epidemics.  It  has  a  profound 
influence  in  the  reaction  to  diet  in  such  cases  and  is  re- 


INFECTION   AND   NUTRITION.  287 

sponsible  to  a  large  degree  for  the  character  of  the  stools 
when  present  in  large  numbers. 

B.  pyocyaneus,  B.  lactis  aerogenes  and  the  proteus 
group  as  specific  factors  are  open  to  question  and  it  is 
more  likely  that  they  were  accompanying  rather  than 
specific  in  reported  epidemics. 

Kendall  and  Day,  making  a  careful  study  of  the  epi- 
demics of  summer  diarrhea  in  Boston,  found  that  during 
the  year  1910  the  epidemic  was  mainly  due  to  dysentery 
bacilli,  fully  75  per  cent,  of  52  cases  being  due  to  these 
organisms.  Streptococci  were  also  present  in  about  60 
per  cent,  of  the  dysentery  cases,  probably  as  secondary  or 
terminal  invaders.  The  summer  of  1911  was  noteworthy 
as  a  "streptococcus"  year;  54  per  cent,  of  146  cases 
studied  harbored  large  numbers  of  these  organisms.  The 
year  of  1912  was  a  "gas  bacillus"  year,  these  organisms 
appearing  in  unusually  large  numbers  in  39  per  cent,  of 
135  cases  examined.  Each  of  the  above  types  was  found 
each  year,  but  the  striking  feature  is  the  shifting  of  the 
dominant  organism  from  year  to  year.  Kendall  con- 
cludes that,  bacteriologically  considered,  these  cases  are 
of  varied  etiology,  caused  by  organisms  of  very  unlike 
characteristics. 

In  contrast  to  this,  studies  of  the  summer  diarrheas 
at  the  Sarah  Morris  Hospital  for  Children  (Chicago) 
during  the  course  of  two  summers,  showed  that  most  of 
them  were  secondary  to  parenteral  infections  (see  page 
280).  Day  worked  both  in  Boston  and  Chicago  cases, 
and  therefore  the  error  could  not  have  been  one  of 
technic.  The  difference  was  probably  due  to  use  of 
boiled  milk  in  Chicago,  and  unboiled  milk  in  the  East. 
The  infection  in  most  cases  probably  being  due  to  organ- 
isms ingested  from  the  upper  respiratory  tract. 

Pathology.  To  the  invasion  of  pathogenic  bacteria 
the  digestive  canal  reacts  by  inflammation  of  the  intes- 
tines (enteritis).  The  large  intestine  is  always  more 
affected,  while  in  the  small  intestine  the  pathological 


288  INFANT   FEEDING. 

process,  as  a  rule,  is  limited  to  its  lower  portion.  How- 
ever, in  cases  secondary  to  infections  of  the  nose  and 
throat,  even  the  gastric  mucosa  may  be  involved.  Mes- 
enteric  lymph-glands  are  swollen.  In  some  cases  the 
bacteria  invade  the  deeper  organs  also,  and  may  be  cul- 
tivated from  the  spleen  and  the  gall-bladder.  Liver  and 
kidneys  show  degenerative  changes  in  severe  cases, 
probably  due  to  the  action  of  toxins.  Occasionally 
other  organs  may  secondarily  become  affected  (otitis, 
pneumonia). 

The  inflammation  of  the  intestines  may  reach  any  de- 
gree of  severity,  and  is  dependent  to  some  extent  at  least 
upon  the  causative  organism,  being,  as  a  rule,  most 
marked  in  cases  in  which  dysentery,  typhoid,  and  strep- 
tococcic  organisms  are  excitants  of  the  pathological 
process. 

It  may  be  a  hyperemia  and  swelling-  associated  with 
exudation  of  excessive  amount  of  mucus  and  occasion- 
ally of  blood,  producing  a  picture  of  catarrhal  gastro- 
enteritis marked  by  mucus,  mucopurulent,  and  occasion- 
ally also  slightly  bloody  diarrheal  stools.  These  cases 
are  caused  by  a  variety  of  bacteria,  and  they  are  often 
secondary  to  infections  of  the  respiratory  tract,  the  same 
micro-organisms  being  causative  in  both  instances.  We 
have  frequently  seen  such  a  clinical  picture  associated 
with  severe  vomiting,  and  a  secondary  acidosis  following 
in  the  course  of  a  streptococcus  sore  throat. 

Intense  swelling  of  Peyer's  patches  in  the  small  intes- 
tine is  seen  in  typhoid  infection.  Sloughing  and  ulcer 
formation  is  far  less  frequent  than  in  adults. 

In  paratyphoid  infections,  while  infiltration  of  Peyer's 
patches  and  solitary  follicles  are  usually  present,  deep 
ulceration  is  lacking,  as  a  rule. 

In  infection  with  dysentery  bacilli,  the  large  intestine  is 
especially  affected,  being  the  seat  of  sero-hemorrhagic 
and  hemorrhagico-purulent  inflammation,  with  marked 


INFECTION   AND   NUTRITION.  289 

tendency  to  formation  of  ulcers  throughout  a  large  part 
of  the  Targe  intestine,  and  less  frequently  in  the  course 
of  the  ileum. 

Again,  we  may  see  marked  intestinal  pathology,  as 
evidenced  by  deep-seated  ulcerations  and  infiltrations  of 
mucosa  and  secondary  inflammation  of  the  submucous 
and  muscular  layer  of  the  intestinal  wall,  which  condition 
is  usually  spoken  of  as  ulc-erative  follicular  colitis,  and 
this  may  be  complicated  by  formation  of  a  pseudomem- 
brane  in  various  areas  throughout  the  large  intestine, 
which  condition  has  been  described  as  a  membranous 
colitis.  In  many  of  these  cases  it  is  difficult  to  determine 
the  exact  bacteriological  factor,  because  of  the  presence 
of  secondary  organisms.  Most  of  these  cases  are  either 
subacute  or  seen  as  secondary  involvement  in  infants  who 
have  suffered  from  repeated  nutritional  disturbances. 

On  the  whole,  in  those  cases  of  inflammation  of  the 
intestinal  tract  due  to  bacterial  infection  and  presenting 
serious  pathological  changes,  the  most  marked  changes 
are  found  in  the  lower  three  feet  of  the  small  intestine 
and  in  the  large  intestine.  While  there  is  very  frequently 
a  disparity  between  the  severity  of  the  clinical  symp- 
toms and  the  pathological  changes  seen  post-mortem  in 
that  not  infrequently  severe  symptoms  are  associated 
with  little  pathology,  on  the  other  hand  marked  patho- 
logical changes  are  almost  invariably  associated  with  a 
severe  clinical  picture. 

Symptoms.  The  symptoms  vary  with  the  individ- 
ual excitant  of  the  disease,  and  thus  also  to  a  certain  ex- 
tent with  the  pathology,  but,  in  general,  the  symptoms 
are  so  variable  and  with  very  few  exceptions  so  little 
characteristic  for  the  particular  excitant  that  the  etio- 
logical  and  pathological  grouping  of  clinical  pictures  is 
impractical.  It  seems  much  better  to  differentiate  the 
various  forms  from  the  clinical  point  of  view. 

Diarrhea  with  slimy  or  purulent  evacuations,  often 
with  blood,  accompanied  by  abdominal  pain,  tenesmus 

19 


290  INFANT   FEEDING. 

and  fever,  are  the  most  characteristic  and  the  most  con- 
stant symptoms  of  enteral  infections. 

The  onset  and  progress  of  enteral  infections,  as  a  rule, 
are  sudden  and  rapid,  and  in  this  way  they  markedly  dif- 
fer from  alimentary  nutritional  disturbances  in  which 
prodromes  consisting  of  milder  symptoms  are  often  pres- 
ent, and  the  progress  is  gradual.  In  enteral  infections  the 
stormy  course  may  result  in  Tapid  production  of  a  very 
severe  picture  of  general  prostration,  and  even  an  early 
fatal  outcome. 

Diarrhea  is  so  constant  that  these  cases  have  been 
designated  as  "infectious  diarrhea,"  and  yet  it  should  be 
remembered  that  typhoid  and  paratyphoid  infections  in 
young  individuals  may  be  associated  with  any  degree  of 
constipation  early  in  the  disease.  The  stools  are,  as  a 
rule,  frequent,  often  one  every  hour,  and  there  are  also 
cases  in  which  the  bowels  seem  to  move  almost  contin- 
uously. The  number  of  stools  varies  also,  according  to 
the  seat  of  the  most  severe  inflammation,  and  they  are 
more  numerous  when  the  large  intestine  is  chiefly 
affected. 

Loss  of  weight,  often  sudden  and  marked,  is  always 
present,  and  is  due  to  many  evacuations,  and  also  to  ac- 
companying nutritional  disturbance. 

Stools.  The  macroscopical  appearance  of  individual 
stools  varies  not  only  with  the  etiological  factor,  but  is 
also  dependent  to  a  great  extent  upon  the  reaction  to 
food,  and  upon  the  intestinal  pathology,  and  is  therefore 
of  little  value  in  the  etiological  diagnosis  of  enteral  in- 
fections. The  size  of  the  stools  is  indirectly  propor- 
tional to  their  number.  In  the  beginning  they  appear  to 
be  of  normal  composition,  but  sooner  or  later  they  are 
composed  chiefly  of  mucus  and  blood,  and  occasionally 
pus  may  be  seen,  even  by  the  unaided  eye.  Portions  of 
the  intestinal  mucous  membrane  are  seen  in  severe  cases 
at  the  time  of  sloughing  and  ulceration.  The  odor  of 
the  stool  varies  with  its  composition,  and  thus  with  the 


INFECTION   AND   NUTRITION.  291 

progress  of  the  disease.  In  the  beginning  the  odor  is  that 
of  the  normal  stool ;  later  stools,  composed  of  mucus  and 
blood,  are  almost  odorless ;  and  those  containing  large 
quantities  of  sloughs  have  often  a  putrefactive  odor. 
The  reaction  of  the  stools  varies  also  with  their  composi- 
tion, being  mostly  alkaline.  In  exceptional  cases  the 
stools  may  not  be  considerably  increased  in  number,  and 
may  contain  neither  mucus,  nor  blood,  nor  pus. 

Abdominal  pain  and  tenesmits,  due  to  irritation  by  the 
bacteria  and  their  products,  and  also  due  to  the  abnormal 
intestinal  contents,  and  to  increased  peristalsis,  and  some- 
times to  distention,  appear  very  early  in  the  disease,  often 
being  the  first  symptoms.  Although  being  severe  usu- 
ally, they  vary  from  a  slight  discomfort  to  excruciating 
•pain,  which  keeps  the  child  constantly  awake,  and,  caus- 
ing exhaustion,  adds  to  the  severity  of  the  case.  Ab- 
dominal distention  is  intermittent,  the  abdomen  being 
usually  sunken.  Abdominal  tenderness  is  not  frequent. 
Anorexia  is  almost  always  present,  while  vomiting  is 
more  commonly  seen  early. 

Fever  is  always  present  in  enteral  infections,  and  varies 
with  the  severity  of  the  infection  and  the  pathology. 
More  often  it  is  not  extreme  after  the  first  exacerbations. 
It  persists  throughout  the  disease. 

Leucocytosis  and  oliguria  are  usually  present. 

Enteral  infections  are  always  associated  with  nutri- 
tional disturbances,  since  the  infection  affects  an  organ 
chiefly  concerned  in  nutritional  processes.  And  nutri- 
tional disturbances,  again,  produce  symptoms  of  their 
own. 

The  course  of  enteral  infections  varies  considerably, 
being  dependent  chiefly  upon  the  nature  of  the  organism 
and  the  stage  of  nutritional  disturbance  that  develops, 
and  also  on  the  nature  of  complications.  Some  cases 
may  be  so  mild  as  to  resemble  subacute  dyspepsia,  and 
only  inability  to  influence  the  fever  by  the  diet  may  point 
to  their  true  nature.  On  the  other  hand,  however,  severe 


292  INFANT   FEEDING. 

toxic  conditions  occur,  being  due  either  to  sepsis  or  to  a 
nutritional  disturbance  which  develops  secondarily  to  in- 
fection. The  duration  of  the  disease  varies  from  a  few 
days  to  several  weeks. 

Complications.  The  great  danger  of  the  infections 
of  the  gastro-intestinal  tract  lies  in  their  tendency  to 
complications,  at  the  head  of  which  stand  nephritis  and 
pneumonia.  Other  complications  are  cysto-pyelitis  and 
various  pyodermatoses,  and  other  pus  infections  and  gen- 
eral pyemia  or  septicemia,  which  start  either  from  the 
skin  or  from  the  diseased  intestines. 

More  important  than  this  is  the  association  of  infec- 
tious diseases  of  the  intestines  with  secondary  nutritional 
disturbances.  It  is  easy  to  understand  that  in  severely 
diseased  intestines  the  normal  digestion  of  food  is  made 
especially  difficult,  and  thus  acid  decomposition  easily 
occurs,  which  in  turn  leads  to  dyspepsia,  and  in  the  wake 
of  these  even  the  alimentary  decomposition  and  alimen- 
tary intoxication  may  be  implanted  upon  the  original  dis- 
ease. The  inanition  caused  by  the  too  prolonged  feeding 
with  an  unbalanced  diet,  such  as  cereal  waters  (flour  in- 
juries, Mehlnahrschaden)  may  in  some  cases  reach  dis- 
astrous gravity.  There  can  be  no  doubt  that  the  majority 
of  the  cases  resulting  in  athrepsia  are  not  due  to  the  in- 
fection alone,  but  also  to  the  inanition  and  other  forms 
of  secondary  nutritional  disturbances,  and  it  is  probable 
that  even  a  part  of  the  severe  ulcerative  forms  and  vari- 
ous complications  develop  on  the  same  foundation.  The 
underfeeding  alone  gradually  decreases  the  general  power 
of  resistance  of  the  body;  it  weakens  also  the  antibac- 
terial functions,  and  thus  the  local  or  general  infection 
may  spread  unimpeded. 

Diagnosis.  In  making  a  diagnosis  it  is  necessary  to 
differentiate  the  enteral  infections  not  only  from  (1) 
alimentary  nutritional  disturbances,  but  also  from  (2) 
nutritional  disturbances  caused  by  parenteral  infections. 
(3)  Diagnosis  of  the  causative  organism  or  group  of 


INFECTION   AND   NUTRITION.  293 

organisms  is  also  of  great  importance  for  the  treatment. 
(4)  Enteral  infections  are  always  complicated  by  nutri- 
tional disturbances,  and  it  is  of  great  importance  to  recog- 
nize the  degree  (simple  infectious  diarrhea,  anhydremia 
and  intoxication)  to  which  the  infant  is  affected. 

In  practice  it  is  often  difficult  to  differentiate  clinically 
the  gastro-intestinal  infection  from  other  forms  of  ali- 
mentary disturbances,  because  neither  bloody  and  puru- 
lent stools  nor  the  finding  of  pathogenic  bacteria  in  the 
stools  in  itself  is  sufficient  for  the  diagnosis  of  enteral 
infection,  except  possibly  in  the  presence  of  typhoid, 
paratyphoid,  and  dysentery  bacilli. 

An  easily  applicable  method  of  differentiation  is  the 
test  for  the  reaction  to  starvation  and  feeding.  Fever 
continuing  after  withdrawal  of  food  speaks  for  infec- 
tious etiology.  Inability  to  influence  the  symptoms  by 
diet  is  to  be  interpreted  in  the  same  sense. 

History  is  of  considerable  importance  in  making  a  dif- 
ferential diagnosis.  The  acute  infectious  diarrhea  starts 
usually  suddenly  in  a  previously  well  baby,  and  pros- 
trates it  at  once,  while  the  alimentary  nutritional  disturb- 
ance comes  on  gradually.  In  the  latter  we  get  a  history 
of  improper  feeding,  of  previous  nutritional  disturbance, 
of  parenteral  infection.  It  is  more  gradually  progressive. 

The  differentiation  between  the  enteral  and  the  paren- 
teral infections  is  somewhat  more  difficult,  and  is  to  be 
made  chiefly  by  exclusion  of  the  parenteral  infection  by 
careful  physical  examination  of  the  patient.  The  bloody, 
purulent  stools  are  usually  absent  in  the  cases  secondary 
to  parenteral  infection. 

The  diagnosis  of  the  causative  organism  is  to  be  made 
by  proper  bacteriological  examination  and  culture  of  the 
stools,  and  by  agglutination  reaction.  Kendall  states  that 
frequently  it  is  very  difficult  to  determine  the  organism 
causing  the  disease,  and  therefore  he  has  attempted  to 
classify  the  causative  organisms  into  two  groups  with  a 


294  INFANT   FEEDING. 

special  reference  to  treatment.1  He  divides  them  into 
two  large  groups:  (1)  the  various  forms  of  dysentery 
bacillus  and  all  other  organisms  except  the  gas  bacillus; 
(2)  the  gas  bacillus  and  the  allied  organisms. 

While  this  classification  of  organisms  for  treatment 
theoretically  offered  great  advantages,  in  our  own  clinical 
work  we  have  not  experienced  the  encouraging  clinical 
results  which  might  be  expected,  and  have  instituted  a 
general  course  of  treatment  based  more  directly  on  the 
severity  of  the  infection  and  the  symptoms  as  presented 
by  the  cases  at  hand. 

Stool  cultures  should  be  made  according  to  the  method 
of  Kendall  for  gas  bacillus.  This  method  is  so  simple 
that  it  may  be  performed  even  outside  of  a  well  equipped 
laboratory.  A  small  portion  of  the  stool  is  added  to  a 
test-tube  of  litmus  milk.  The  test-tube  is  then  heated  on 
the  water-bath,  and  left  in  the  boiling  water  for  three  min- 
utes. By  this  procedure  all  the  bacteria  in  the  stool  that 
are  not  in  the  stage  of  spores,  are  killed,  and  the  bacteria 
develop  unrestrained  from  the  spores  subsequently.  Gas 
bacilli,  being  sporogenous,  survive  the  boiling.  The  test- 
tube  is  finally  incubated  at  a  body  temperature  for  about 
twenty-four  hours.  In  the  presence  of  large  numbers  of 
gas  bacilli  a  large  part  of  the  casein  is  dissolved,  but  the 
remaining  casein  is  filled  with  holes,  as  if  shot  to  pieces, 
and  somewhat  pinkish  in  color.  .  The  odor  reminds  one 
of  rancid  butter,  and  is  due  to  formation  of  butyric  acid. 
The  true  reaction  may  be  easily  differentiated  from  the 
pseudoreactions,  in  which  some  liquefaction  of  casein 
also  occurs,  but  in  which  the  shotted  appearance  of  the 
residual  casein  and  the  odor  of  butyric  acid  are  absent. 

Differential  studies  for  typhoid,  paratyphoid,  and  dys- 
entery bacilli  on  endomedium  and  Russell's  double  sugar 
medium,  and  by  further  fermentation  tests,  are  indicated 
in  the  presence  of  epidemic  or  severe  endemic  cases. 


1  Kendall  and  Smith :  Boston  Med.  and  Surg.  Jour.,  1910,  clxiii, 
578. 


INFECTION   AND   NUTRITION.  295 

While  agglutination  reactions  are  uncertain  in  very 
young  infants,  because  of  the  slight  tendency  to  the  for- 
mation of.  agglutinins,  in  older  infants  and  children  they 
are  of  very  considerable  value,  as  demonstrated  by  the 
study  of  agglutinins  by  the  author  at  Cook  County  and 
Sarah  Morris  Hospitals  during  the  year  1914.  In  a  series 
of  30  cases  studied  in  which  agglutinations  were  made  for 
typhoid,  paratyphoid  (alpha,  beta,  and  Morgan),  dysen- 
tery (Shiga  and  Flexner),  and  colon  bacilli,  the  follow- 
ing organisms  were  demonstrated:  typhoid,  2;  paraty- 
phoid (Morgan),  1;  dysentery,  2.  All  of  these  cases 
yielded  the  respective  organisms  in  large  numbers  from 
their  stool  cultures.  This  method  of  examination  is 
easily  carried  out  in  a  well  regulated  laboratory,  and  is 
worthy  of  further  consideration  in  the  presence  of  an 
epidemic  of  enteritis  or  isolated  cases  of  severe  enteral 
infection. 

The  stage  of  the  nutritional  disturbance  is  best  diag- 
nosed by  the  reaction  of  the  temperature  and  toxic  symp- 
toms to  complete  withdrawal  of  food,  and  presence  or 
absence  of  paradoxical  reaction.  Starvation  in  the  pres- 
ence of  infection  must  always  be  recognized  as  a  danger- 
ous procedure. 

Prognosis.  The  prognosis  of  enteritis  is,  in  general 
favorable.  Death  is  almost  always  due  to  complications 
with  septic  affections  or  nutritional  disturbances. 

The  mortality  rate  varies  greatly  in  different  epidemics. 
The  same  organism  may  in  one  year  cause  a  widespread 
mild  epidemic;  at  another  it  may  be  associated  with  a 
high  mortality.  Epidemics  among  institutional  infants 
must  always  be  given  serious  consideration. 

In  infants  and  younger  children  the  prognosis  depends 
essentially  upon  the  ability  of  the  physician  to  apply  the 
proper  dietetic  methods  suitable  for  the  particular  case. 
If  he  succeeds — and  this  is  at  present  possible  in  very 
many  cases — avoiding  grave  secondary  nutritional  dis- 
turbances, then  he  will  be  able  to  save  a  surprisingly 


296  INFANT   FEEDING. 

large  percentage  of  cases;  if  he  is  unsuccessful  in  this 
direction,  then  his  results  will  be  unsatisfactory. 

Treatment.  Prophylaxis.  In  the  etiology  of  enteral 
infections  several  facts  based  on  bacteriological  studies 
and  clinical  observations  stand  out  so  prominently  that 
the  methods  of  prophylaxis  must  be  based  upon  them  in 
order  to  be  successful. 

1.  In  the  great  majority  of  cases  the  infection  is  intro- 
duced with  the  food.    Whenever  intestinal  infection  oc- 
curs in  a  breast-fed  infant  in  a  private  home,  the  first 
thought  should  be  that  the  infant  was  probably  getting 
other  food  besides  mother's  milk,  and  only  after  exclu- 
sion of  this  probability  should  the  causes  be  looked  for 
in  the  environment  of  the  infant,  especially  the  cleanli- 
ness of  the  mother  and  the  general  hygiene  of  the  home. 
In  artificially  fed  infants  the  prophylaxis  of  enteral  in- 
fections consists  of  obtaining  pure  and  wholesome  milk, 
keeping  it  clean,  boiling  when  in  doubt,  and  careful  prep- 
aration of  proper  mixtures. 

2.  In  many  cases  the  infection  occurs  by  contact,  espe- 
cially in  institutions.    Isolation  of  severe  cases  of  intes- 
tinal infection  is  therefore  essential,  and  isolation  of  all 
suspicious  cases  advisable,  especially  in  institutions. 

3.  The  environment  of  the  infant,  and  especially  lack 
of  proper  cleanliness  generally,  and  in  preparation  of 
foods  especially,  are  very  frequently  predisposing  and 
accessory  factors.    The  methods  instituted  to  counteract 
these  influences  must,  of  course,  be  adapted  to  the  in- 
dividual case. 

4.  Parenteral  infections  are  often  followed  by  enteral 
infections.      Proper   treatment   of    parenteral    infection, 
special  attention  to  the  diet  and  general  hygiene,  are  the 
keynote  of  prophylaxis  in  these  cases,  the  possibility  of 
secondary  enteral  infection  being  constantly  kept  in  mind. 

5.  Alimentary  nutritional  disturbances  increase  suscep- 
tibility to  any  form  of  infection,  and  especially  to  enteral 
infection,  and  the  prophylaxis  of  secondary  enteral  in- 


INFECTION  AND   NUTRITION.  297 

fections  coincides  practically  with  the  prevention  and 
proper  treatment  of  these  nutritional  disturbances.  (See 
also  "Susceptibility  Influenced  by  Nutrition,"  p.  276.) 

Initial.  The  object  of  the  initial  treatment  is  to  de- 
crease as  much  as  possible  the  number  of  bacteria  present 
in  the  intestine,  and  the  removal  of  irritating  intestinal 
contents.  Intestinal  disinfection  by  drugs  is  impossible; 
and  the  cleansing  of  the  intestines  by  the  administration 
of  large  quantities  of  inert  fluids,  enemata,  and  possibly 
an  initial  laxative,  is  the  best  that  can  be  done  in  this 
direction. 

Castor  oil,  which  is  usually  taken  plain  without  any 
difficulty  by  infants,  in  doses  of  1  to  2  teaspoonfuls,  is 
the  best  laxative  for  these  cases,  since  it  causes  very 
little  intestinal  irritation.  Only  in  cases  where  it  is 
vomited,  we  should  resort  to  magma  magnesise  (l/2  to  4 
teaspoonfuls),  or  to  calomel,  0.06  gram  (1  gr.),  given 
in  doses  of  0.015  gram  (%  gr-)  every  half  an  hour  until 
two  to  four  doses  are  given.  Calomel  should  always  be 
administered  with  caution  and  is  best  used  with  sodium 
bicarbonate.  The  calomel  can  be  followed  to  advantage 
with  1  or  2  teaspoonfuls  of  magma  magnesiae. 

An  enema  of  physiological  saline  (1  teaspoonful  of 
salt  to  1  pint  of  water)  is  useful. 

All  food  should  be  stopped  for  from  six  to  twelve 
hours.  It  is  not  desirable,  as  a  rule,  to  withhold  the  food 
longer  than  this  time. 

Water  should  be  given  freely  during  the  starvation 
period.  The  water  may  be  given  either  warm  or  cool,  or  in 
the  form  of  weak  tea.  Saccharin  may  be  used  to  sweeten 
it,  using  0.01  gram  (%  g1"-)  of  saccharin  to  8  ounces 
of  water,  if  desired.  In  presence  of  marked  anorexia 
or  refusal  of  fluid  on  the  part  of  the  infant,  the  water  or 
tea  must  be  administered  by  catheter.  In  persistent 
vomiting,  frequent  resort  to  gastric  lavage  with  1  per 
cent,  sodium  bicarbonate  solution  will  relieve  vomiting, 
and  be  followed  by  retention  of  fluids  given  by  mouth. 


298  INFANT   FEEDING. 

When  the  latter  does  not  relieve  the  vomiting,  physiologi- 
cal saline  solution  or  Ringer's  solution  must  be  given 
either  by  rectum  or  subcutaneously. 

Local  and  Medicinal  Treatment.  Abdominal  pain  and 
tenesmus  are  often  so  severe  that  they  require  a  special 
treatment.  Moist  heat  in  the  form  of  compresses,  hot 
water  bottles  or  electric  pads  should  be  given  preference, 
and  only  in  cases  in  which  they  do  not  afford  relief 
should  recourse  be  had  to  opium  or  morphine.  Tincture 
of  opium  in  doses  of  3  to  5  drops  may  be  given  in  10  per 
cent,  starch  solution  by  the  rectum,  or  0.01  to  0.03  gram 
(%  to  l/2  gr.)  of  pulvis  ipecacuanhse  et  opii  (Dover's 
powder)  (beware  of  vomiting),  or  5  to  20  drops  of 
tinctura  opii  camphorata  (paregoric)  by  mouth.  In  some 
cases  1  or  2  doses  of  morphine  may  be  preferable,  since 
it  decreases  the  peristalsis  less  markedly  than  opium ;  the 
dangers  of  its  administration  to  infants  must  be  remem- 
bered, and  the  dosage  must  be  minimal  (0.0003  to  0.001 
gram— %oo  to  %0  gr.).  Atropin— %500  to  %0o  gr.  and 
epinephrin  in  1 :1000  solution,  1  to  5  minims,  may  be  in- 
dicated in  the  presence  of  marked  atony  of  the  intestinal 
tract.  Argyrol  in  6  grain  doses,  administered  as  a  10 
per  cent,  solution,  may  have  a  beneficial  influence.  (See 
page  236.) 

Stimulants  are  indicated  in  some  cases  of  extreme  ex- 
haustion, and  in  cases  of  sudden  collapse.  In  the  ab- 
sence of  hyperexcitability  of  the  nervous  system,  strych- 
nin is  the  most  generally  useful  stimulant.  It  is  given 
in  doses  of  0.00005  to  0.0003  gram  (%000  to  %0o  gr.). 
Caffein  in  the  form  of  caffein  sodium  benzoate,  or 
titrated  caffein,  are  of  value,  and  is  given  in  doses  of 
0.01  to  0.03  gram  (%  to  y2  gr.).  Camphor  0.05  to  0.10 
gram  (1  to  2  gr.)  dissolved  in  sterile  oil  may  be  injected 
subcutaneously  in  emergency,  to  be  repeated  as  indicated. 

Special  symptoms  and  conditions  arising  during  the 
course  of  the  disease,  as  high  fever,  excessive  vomit- 
ing, symptoms  of  nervous  excitation,  or  extreme  depres- 


INFECTION    AND    NUTRITION.  299 

sion,  are  to  be  treated  as  detailed  under  Anhydremia 
page  259). 

Injections  of  silver  nitrate  are  of  value  in  some  cases 
where  blood  and  pus  persist  in  the  stool  even  after  the 
subsidence  of  acute  symptoms,  and  especially  in  dysen- 
tery. Before  an  injection  is  given,  the  colon  should  be 
irrigated  first  with  sterile  water  (not  saline).  One 
per  cent,  silver  nitrate  solution  is  then  injected  in  a  suit- 
able quantity.  If  it  causes  any  pain  or  irritation,  it 
should  be  washed  out  with  saline  solution.  It  should  not 
be  repeated  more  often  than  once  a  day,  and  if  three 
injections  do  not  result  in  marked  improvement  it  is 
better  to  discontinue  them. 

Dietetic  Treatment.  Human  Milk.  The  ideal  treat- 
ment for  all  cases  of  intestinal  infections  is  by  feeding 
with  human  milk,  and  whenever  obtainable,  more  es- 
pecially in  the  severe  types  it  is  by  all  means  the  diet  of 
choice.  Feeding  with  human  milk,  especially  in  young 
infants,  produces  very  good  results,  because  it  retards 
the  complicating  nutritional  disturbance,  and  thus  favors 
healing. 

Artificial  Feeding.  From  the  great  number  of  food 
mixtures  that  have  been  advised  for  enteral  infections, 
we  may  judge  as  to  the  difficulty  of  feeding  in  such  cases. 
It  is  probable  that  success  may  be  obtained  with  any 
feeding  which  prevents  the  aggravation  of  nutritional 
disturbance,  and  favorably  influences  the  nutritional  dis- 
turbance which  may  exist.  Feeding  with  albumin  milk, 
skim  and  buttermilk,  and  cereal  mixtures  and  whey- 
cereal  mixture  (Frank)  offer  the  least  risk. 

Prolonged  starvation  by  insufficient  diet  or  by  refusal 
on  the  part  of  the  infant  to  take  the  prescribed  diet  is 
always  disastrous,  and  must  be  avoided.  After  six,  or 
at  the  most  twelve,  hours  on  the  tea  diet  the  infant  is 
placed  on  cereal  water  (barley,  rice,  or  flour  ball),  using 
1  tablespoonful  of  the  flour  to  a  pint  of  water  in  young 
infants,  and  2  tablespoonfuls  to  the  pint  of  water  in 


300  INFANT   FEEDING. 

infants  over  1  year.  After  twelve  to  twenty-four  hours 
on  the  above  diet  an  ounce  of  young  chicken,  veal  or 
lamb  broth  can  be  added  to  the  above  cereal  waters, 
seasoning  with  a  small  amount  of  salt.  If  the  child  will 
take  the  food,  it  may  be  given  in  the  same  quantities  to 
which  the  child  has  been  accustomed,  or  smaller  quanti- 
ties at  more  frequent  intervals. 

By  far  the  best  results  obtained  in  our  private  and  hos- 
pital work  have  been  by  instituting  feeding  with  the  al- 
bumin milk1  of  Finkelstein  after  the  first  twenty-four 
hours  on  an  inert  diet.  The  value  of  the  albumin  milk 
may  be  explained  by  the  fact  that  it  is  easily  digestible, 
containing  moderate  quantities  of  fat  and  sugar  and  finely 
divided  casein,  which  is  easily  digested  in  this  form.  The 
rules  to  be  followed  in  the  feeding  with  albumin  milk 
are  described  under  Diarrheal  Disturbances.  (Page 
234.)  This  diet  is  also  to  be  recommended  in  home  prac- 
tice, wherever  it  is  possible  to  obtain  it,  either  from  a 
neighboring  hospital  or  by  instruction  of  the  nurse  or  of 
the  mother.  Feeding  with  albumin  milk  should  be  be- 
gun after  twenty- four  hours  on  the  tea  and  cereal  water 
diet.  Sufficient  quantity  of  inert  fluid,  either  in  the  form 
of  water,  tea,  or  cereal  water  should  be  given  with  or 
between  the  small  feedings  of  albumin  milk.  One  of  the 
gravest  dangers  in  the  severe  infections  is  that  the  in- 
fants are  likely  to  take  too  little  rather  than  too  large 
quantities,  and  are  especially  prone  to  vomit  when  the 
food  is  forced  upon  them. 

Boiled  skim  buttermilk  or  skim  milk  with  starch  or 
flour  ball  added  (1  tablespoonful  to  the  pint)  may  be 
used  as  substitute,  if  albumin  milk  cannot  be  obtained. 
They  are,  however,  not  so  efficacious.  They  should  be 
fed  in  small  quantities,  as  recommended  for  albumin 
milk. 


1  Dilutions  of  the  dry  forms  in  which  it  is  obtainable  on  the 
market  will  answer.     (See  Appendix.) 


INFECTION   AND   NUTRITION.  3Q1 

Chymogen  milk  (either  made  from  the  whole  milk,  or 
in  severe  types  from  skim  milk),  either  diluted  or  in 
small  quantities,  if  given  full  strength,  is  frequently  re- 
tained when  the  stomach  is  very  irritable,  and  where  the 
child  objects  to  the  less  palatable  albumin  milk  and  but- 
termilk mixtures. 

For  further  treatment  see  Diarrheal  Disturbances. 

"The  whey-cereal  mixture  therapy  of  Frank  deserves 
mention.  It  is  administered  as  follows : 

1st  day:  Initial  starvation  period  on  tea  for  not  longer 
than  twelve  hours. 

2d  day :  Feed  five  times  50  grams  whey  and  50  grams 
cereal  gruel  prepared  from  crushed  grain. 

3d  day:  Increase  to  60  grams  whey  and  60  grams 
cereal  gruel. 

4th  day :  75  grams  whey  and  75  grams  gruel. 

5th  to  8th  day :  Not  later  than  on  the  fifth  to  eighth 
day  of  treatment  replace  a  tablespoonful  of  whey  by 
tablespoonful  of  milk.  Increases  of  milk  to  be  guided  by 
the  infant's  progress  and  needs. 

9th  to  llth  day:  Increase  the  addition  of  milk 
gradually. 

12th  to  14th  day :  Even  in  the  grave  case  400  grams  of 
milk  and  400  grams  of  cereal  gruels  and  200  grams  of 
meat  broth  must  be  given,  and  not  later  than  in  this  time 
the  broth  is  to  be  prepared  with  strained  rice  or  farina. 
In  infants  over  1  year,  beginning  with  the  tenth  day, 
finely  scraped  beef  may  be  added." 

A  careful  record  should  be  kept  of  the  exact  amount 
of  milk  and  other  fluids  taken  in  each  twenty-four  hours, 
and,  where  possible,  the  child  should  be  weighed  daily  to 
ascertain  the  loss  in  weight. 

The  dietetic  therapy  has  never  such  a  prompt  result  as 
in  alimentary  nutritional  disturbances.  Even  in  favor- 
able cases  the  disease  (purulent  and  bloody  stools,  fever) 
continues  for  one  week;  in  unfavorable  cases,  several 
weeks.  Strict  adherence  to  the  food  regime  once  insti- 


302  INFANT   FEEDING. 

tuted  is  desirable.  In  these  cases  no  greater  mistake 
could  be  made  than  to  change  diet  with  introduction  of 
repeated  hunger  days,  or  to  allow  the  infant  to  remain  on 
small  quantities  of  food.  Thus,  an  infant  suffering  from 
infection  succumbs  often  not  to  the  infection,  nor  to  the 
nutritional  disturbance,  but  to  inanition. 

Diet  in  Convalescence.  The  problem  of  nutrition 
offers  great  difficulties,  even  after  the  subsidence  of  the 
fever,  and  following  the  improvement  in  the  number  and 
character  of  the  stools,  as  it  is  frequently  necessary  to 
keep  the  infant  on  a  restricted  diet  for  from  one  to  three 
weeks.  Only  rarely  it  is  possible  to  feed  sufficient  caloric 
units  for  the  maintenance  of  weight  during  the  first  and 
the  second  weeks  of  the  illness.  Where  possible,  the 
albumin  milk,  buttermilk,  skim  milk,  and  chymogen  milk 
and  cereal  gruels  should  be  gradually  increased,  and 
these  increases  in  quantity  should  be  maintained  even  in 
the  presence  of  moderately  bad  stools  if  vomiting  is  ab- 
sent, unless  one  becomes  convinced  that  one  or  the  other 
of  the  food  elements  is  absolutely  detrimental  to  the 
infant's  welfare. 

It  is  our  desire  to  impress  that  possibly  the  gravest  dan- 
ger to  the  infant  during  the  period  of  convalescence  is 
that  of  underfeeding.  Upon  the  return  to  milk  mixture 
small  quantities  of  boiled  milk,  low  in  fat  (albumin  milk, 
buttermilk,  skim  milk)  should  at  first  be  used.  This  may 
be  accomplished  by  adding  it  to  the  cereal  gruels.  Dur- 
ing this  stage  beef  juice  broths,  egg  albumin,  coddled 
egg  (prepared  as  for  typhoid  fever  patients),  zwieback 
crumbs,  pap,  custards,  and  junket  may  be  added.  Under 
conditions  where  ideal  milk  and  milk  preparations  can- 
not be  obtained,  we  have  found  that  not  infrequently  the 
better  brands  of  evaporated  milk,  as  obtained  on  the  open 
market,  are  useful,  when  properly  diluted.  The  use  of 
condensed  milk  should  be  avoided. 

The  obstinate  constipation  which  is  sometimes  seen 
during  convalescence  should  be  treated  with  the  utmost 


INFECTION  AND  NUTRITION.  303 

conservatism  along  the  lines  as  laid  down  for  constipa- 
tion. The  infant  should  have  at  least  one  evacuation  of 
the  bowels  daily.  A  saline  enema  is  usually  sufficient  to 
produce  this  result. 


PART  v. 

Rickets  (Rachitis). 


RICKETS  is  a  chronic  general  disorder  of  nutrition. 
The  predisposing  etiological  factors  have  been,  to  a  con- 
siderable degree,  clarified  by  recent  investigations  and 
it  is  to  be  expected  that  from  the  clinical  and  technical 
studies  now  in  progress,  considerable  new  knowledge  as 
to  the  exact  etiology  will  be  forthcoming  in  the  near 
future. 

The  pathological  changes,  while  most  evident  in  the 
osseous  structure,  may  involve  all  of  the  body  tissues 
and  organs,  including  the  nervous,  muscular,  respiratory 
and  circulatory  systems,  the  blood-making  organs,  liver, 
skin,  hair,  teeth  and  nails. 

N  Its  clinical  manifestations  are  most  commonly  evi- 
//denced  in  the  second  half  of  the  first  year  in  the  full 
term  infant.  In  the  premature  and  congenitally  diseased 
infants,  and  not  infrequently  in  other  infants,  it  can  be 
diagnosed  even  before  the  third  month  of  life.  Radio- 
graphic  diagnosis  is  usually  possible  before  clinical  signs 
are  sufficiently  manifest  to  warrant  a  conclusive  diag- 
nosis^ However,  in  the  first  stages  they  are  frequently 
overlooked  because  of  the  permeability  of  the  rarified 
structure  to  the  roentgen  rays.  The  bones  may  be  but 
slightly  increased  in  density  over  the  surrounding  soft 
tissues.  The  diagnosis  is  usually  made  upon  the  pathog- 
nomonic  bone  lesions  of  the  second  and  third  stages. 
The  bone  lesions  of  the  first  stage  are  less  frequently 
recognized  but  are  of  even  greater  importance  for  the 
adoption  of  proper  hygienic,  dietetic,  and  medicinal  thera- 
peutics for  the  prevention  of  permanent  tissue  changes 
(304) 


RICKETS.  305 

and  deformities.  The  treatment  demands  a  general 
knowledge  of  all  of  the  possible  underlying  etiological 
factors,  the  associated  general  systemic  as  well  as  the 
bone  changes  and  the  possible  progressive  bone  deformi- 
ties which  may  develop  even  after  the  predisposing  fac- 
tors have  been  removed  and  the  acute  process  arrested. 

Etiology.  Most  of  the  theories  as  to  the  exciting 
causes  can  be  grouped  into  four  classes,  namely:  die^ 
tctic,  hygienic^infectimis,  and  endocrinous. 

While  this  disease  is  in  all  probability  primarily  a  diet- 
etic___disorder,  in  most  cases  in  the  human,  improper 
hygienic  conditions  and  infections  may  hasten  the  de- 
velopment of  the  pathognomonic  bone  and  systemic 
changes  and  precipitate  the  clinical  manifestations,  more 
especially  of  the  secondary  complications. 

Rickets  is  the  most  common  chronic  disorder  of  in- 
fants  living  in  the  Temperate  Zone.  Schmorl,1  in  a 
series  of  histologic  studies,  found  that  90  per  cent,  of 
the  children  in  his  Dresden  clinic,  dying  before  the  age 
of  4  years  and  examined  at  autopsy,  had  rickets,  either 
manifest  or  latent.  Dick-2  found  that  80  per  cent,  of 
the  children  examined  in  the  London  county  schools  had 
the  disease  or  had  suffered  from  it  previously.  Kas- 
sowitz3  calculated  that  90  per  cent,  of  the  children  in 
the  out-patient  department  of  his  Vienna  clinic  were 
rachitic.  Epstein4  gives  about  the  same  figures  for 
Prague,  and  Kissel5  for  Moscow.  Engel6  states  that 
n\  (^enrmnv.  during  the  late  war,  all  young  children  were 
affected  to  some  degree.  He  attributes  this  especially 
to  the  lack  of  fresh  milk  and  fats  during  the  war. 


1  Schmorl :  Ergebnisse  der  Inneren  Medizin  u.  Kinderheilkunde, 
1909,  p.  403. 

2  Dick,  L. :  Proc.  of  Roy.  Soc.  Med.,  1915— Brit.  Jour.  Dis.  of 
Children,  13—332,  Nov.  16. 

3  Kassowitz  :  Modern  Clinical  Medicine — Dis.  of  Children,  Julius 
Springer,  Berlin,  1910,  p.  239. 

4-  5  Epstein  and  Kissel :  Ibid,  p.  239. 
6 Engel:  Lancet  1,  188,  Jan.  24,  1920. 

20 


306  INFANT  FEEDING. 

E.  J.  Huenekens1  reports  that  39  per  cent,  of  the  in- 
fants in  his  Minneapolis  Welfare  Clinic  showed  definite 
clinical  signs  of  the  disease.  Hess2  reports  90  per  cent, 
of  the  infants  in  a  New  York  City  infants'  asylum  as 
showing  evidence  of  rickets. 

It  must  be  remembered  that  the  figures  above  quoted 
are  taken  from  patients  among  the  poorer  classes. 
Abroad  and  in  this  country  outpatients  are  also  com- 
posed largely  of  a  class,  many  of  whom  would  be  sub- 
jects of  improper  artificial  feeding  or  as  disastrous 
underfeeding,  or  improperly  balanced  diet  and  overwork 
in  the  lactating  mother.  These  figures  must  be  neces- 
sarily high  when  compared  with  those  of  the  better 
classes,  and  more  especially  children  from  rural  districts, 
who  live  in  the  open  and  receive  an  abundance  of  fresh 
milk  and  green  vegetables. 

Interesting  and  important  is  the  recognition  of  the 
effect  on  the  development  of  rickets  in  the  offspring 
due  to  the  changes  of  climate,  environment  and  diet  in 
the  parent. 

,    In  the  United  States  almost  all  the  negro  infants  in 
/northern  cities  have  rickets,   whether  bottle-  or  breast- 
Ifed,  although  it  is  more  frequently  of  a  severer  type  in 
//the  artificially   fed.     It  is   far  less   frequent  in  negroes 
of  the  southern  states  and  uncommon  in  negroes  of  Cuba 
and  the  West  Indies.3    The  condition  is  also  very  preva- 
lent among  Italians  in  the  United   States,  although  in- 
frequently seen  in  the  rural  districts  of  Italy.     It  occurs 
more  commonly  and  severely  among  the  poorer  of  these 
individuals. 

Hess  and  Unger  found  that  the  diets  of  lactating 
northern   negro  mothers  were  deficient  in   fresh  vege- 
tables   and    fruit,    and    contained    an    excess    of    carbo- 
,  hydrates,  the  diets,  therefore,  being  poor  in  calcium,  phos- 

1  Huenekens,  E.  J. :  Jour.  Lancet,  37,  804,  Dec.  15,  1917. 

2  Hess,  A. :  Jour.  Am.  Med.  Assoc.,  76—698,  March  12,  1921. 

3  Hess  and  Unger :  Jour.  Am.  Med.  Assoc.,  70 — 900,  1918. 


RICKETS.  307 

phate  and  the  vitamines.  It  must  be  remembered  that 
the  human  body  in  all  probability  cannot  synthesize  the 
vitamines  but  must  depend  upon  the  amount  eaten  for 
that  to  be  contained  in  breast  milk.  The  nother's  diet 


thereby  directly  influences  the  amount  fed  to  th 
lings.  The  same  factors,  in  all  probability,  play  an  im- 
portant role  among  the  Italian  immigrants.  Both  of 
these  classes  of  individuals  also  show  a  tendency  to  nurse 
their  offspring  beyond  the  point  of  their  physical  and 
physiological  capacity. 

Neve1  called  attention  to  the  fact  that  rickets  is  ex- 
ceedingly rare  in  parts  of  India  where  infants  live  under 
the  worst  conditions  of  hygiene  and  diet,  but  where  sun- 
light, to  which  they  are  almost  constantly  exposed, 
abounds.  Similar  observations  have  been  made  in  the 
Hebrides,  off  the  coast  of  Scotland,  where  many  infants 
live  in  dark,  damp  houses  during  their  first  year,  but  in 
whom  rickets  is  rare,  due  to  the  fact  that  the  mothers 
live  largely  on  fish,  especially  codfish  livers,  and  milk 
products  and  moderate  amounts  of  vegetables.  On  the 
mainland  of  Scotland,  where  the  diet  of  the  mothers  is 
largely  made  up  of  milled  cereals,  muscle  meat,  and 
potatoes,  rickets  is  very  prevalent  although  the  hygienic 
surroundings  are  much  better. 

Season.  It  is  more  active  in  the  winter  and  spring 
months  and  in  this  peculiarity,  hygiene,  lack  of  exposure 
to  sunlight,  insufficiency  of  fresh  foods  in  the  mother's 
or  cow's  diets,  and  intercurrent  infections  may  one  and 
all  be  contributory  factors. 

The  age  of  onset  varies  considerably.  In  the  mature 
infant  the  symptoms  usually  manifest  themselves  be- 
tween the  sixth  and  eighteenth  months.  Some  observers 
describe  as  congenital  rickets,  a  condition  involving  the 
osseous  system  which  develops  intra-uterine,  presenting 
similar  pathological  findings  at  birth.  There  has  been  a 
great  deal  of  contention  as  to  the  exact  nature  of  these 

i  Neve,  E.  F.  :  Brit.  M.  ].,  Vol.  1,  518,  1919. 


308  INFANT  FEEDING. 

cases;  they  undoubtedly,  however,  belong  to  the  osteo- 
genesis  imperfecta  or  osteopathyrosis  group. 

Heredity  has  been  designated  as  a  predisposing  factor 
in  exceptional  cases. 

Prematurity  is  a  predisposing  factor  to  the  develop- 
ment of  the  disease  and  the  more  prematurely  born  and 
consequently  the  more  poorly  the  physiological  func- 
tions are  developed,  the  greater  likelihood  is  there  that 
the  infant  will  suffer  from  rickets.  Huenekens1  found 
92  per  cent,  of  his  premature  and  twin  pregnancies 
showed  rickets  in  his  series  of  sixty  cases.  He  reports 
that  81  per  cent,  developed  clinical  evidence  of  rickets 
between  the  third  and  fourth  month  of  life.  Many  of 
my  prematures  developed  clinically  evident  rickets  be- 
fore the  end  of  their  second  month.  This  frequency 
and  early  development  may  be  due  to  the  fact  that  the 
mineral  content  of  prematures  is  below  normal,  as  two- 
thirds  of  the  minerals  are  deposited  during  the  last  few 
months  of  fetal  life,  the  fetus  at  six  months  containing 
thirty  grams  and  at  nine  months  one  hundred  grams. — 
Birk.2  In  the  newborn,  fully  75  per  cent,  of  the  ash 
content  consists  of  calcium  and  phosphate,  consequently 
rickets  being  a  disturbance  in  the  calcium  and  phosphate 
metabolism,  the  more  premature  the  infant,  the  greater 
the  deficiency  in  calcium  and  phosphorus,  so  that  the 
surplus  supply  is  exhausted  earlier  than  in  the  full  term. 

Underfeeding  is  another  factor  in  the  development 
of  rickets  in  the  premature.  The  low  calcium  content 
of  human  milk  and  the  difficulty  of  metabolizing  even 
this  food  in  sufficient  quantities  to  prevent  drawing 
on  the  inherited  supply  may  be  an  active  factor. 
Huenekens1  believes  that  this  condition  in  the  prema- 
ture may  be  a  pseudo-rickets  because  It  is  based  upon 
a  deficiency  in  calcium  rather  than  a  disturbed  calcium 
metabolism  as  in  true  rickets. 


1  Huenekens :  Jour.  Lancet,  xxxvii,  804,  Dec.  15,  1917. 

2  Birk  and  Orgler :  Monatschr.  f .  Kinderh.  1,  1910,  544. 


RICKETS. 


309 


Diet.  The  artificially  fed  are  especially  prone  to  de- 
velop severe  rickets.  If  the  diet  contains  sufficient  milk, 
the  tendency  to  develop  the  disease  is  less  than  when 
fed  mainly  on  cereals  and  proprietary  cereal  foods  with 
only  small  amounts  of  milk. 

McCollum,  Shipley  and  their  co-workers,1  in  a  study 
of  the  effect  on  the  growth  and  development  in  rats  by 
the   feeding  of  more  than  300  different  diets  came  to 
the  conclusion  that  the  etiological  factor  is  to  be  found 
in   an   improper   dietetic   regimen.      They    were   able   to 
produce    approximately    normal    nutrition    and    normal 
skeletal   growth    when   properly   constructed   diets   were 
fed.     They  were  able  to  develop  pathological  conditions 
in    rats    corresponding    in    all    fundamental    respects   to 
rickets  in  humans  through  dietetic  insufficiencies :   ( 1 )   By 
diminishing  the   phosphorus  and   supplying  the  calcium 
in  optimal  quantities  or  in  excess,  or   (2)   by  reducing 
rthe  calcium  and  maintaining  the  phosphorus  at  a  con- 
centration somewhere  near  the  optimal.     They  believe 
that  rickets  is  essentially  an  expression  on  the  part  of 
the  skeleton  of  disturbed  relations  between  the  calcium 
and  phosphate  ions  of  the  body  fluids  and  that  there  are 
two  main  kinds  of  rickets:    one  characterized  by  a  nor- 
/  mal   or  nearly   normal   blood  calcium  and  a  low  blood 
/  phosphorus    (low   phosphorus   rickets)  ;  the   other  by  a 
I     normal   or   nearly  normal  blood   phosphorus  but  a  low 
I    blood  calcium    (low  calcium  rickets). 

Due  to  the  fact  that  when  they  fed  diets  containing 
a  complete  salt  mixture,  the  rats  did  not  develop  rickets, 
even  when  there  was  an  absence  of  fat-soluble  vita- 
mine  in  the  diet,  they  concluded  that  a  deficiency  in  this 
substance  cannot  be  the  sole  cause  of  rickets.  They, 


i  McCollum,  Simmonds,  Parsons,  Shipley:  Jour.  Biol.  Chem., 
Vol.  45,  333,  1921.  Shipley,  Park,  McCollum,  Simmonds:  John 
Hopkins  Hosp.  Bull.,  Vol.  32,  160,  1921.  McCollum,  Simmonds, 
Shipley,  Park :  Jour.  Biol.  Chem.,  Vol.  50,  5,  1921.  Shipley,  Park, 
McCollum,  Simmonds:  Am.  Jour.  Dis.  of  Children,  Vol.  23,  91, 
1922. 


310  INFANT  FEEDING. 

however,  feel  that  these  findings  should  not  exclude  the 
fat-soluble  substances  from  consideration  as  etiological 
factors  in  the  production  of  rickets  and  kindred  diseases, 
believing  that  there  is  a  possibility  that  the  blood  phos- 
phate and  calcium  level  may  be  determined  in  part  by 
the  amount  of  fat-soluble  substances  available  for  the 
needs  of  the  organism. 

They  pursued  investigations  with  a  view  to  determin- 
ing the  nature  of  the  substances  contained  in  certain 
animal  fats  which  protect  the  skeleton  when  the  calcium 
content  of  the  diet  is  unfavorable  to  the  formation  of 
normal  bone.  In  this  series  of  observations  the  phos- 
phorus content  was  in  every  case  not  far  from  the 
optimal.  They  were  led  to  the  conclusion  that  codliver 
oil  contains  in  abundance  some  substance  which  is  pres- 
ent in  butter  fat  in  but  very  slight  amounts  and  which 
exerts  a  direct  influence  on  the  bone  development. 
They  further  believe  that  this  substance  is  apparently 
distinct  from  fat-soluble  A. 

They  made  further  studies  on  the  effect  of  sunlight 
and  ultra-violet  rays  on  bone  development.  These  ex- 
periments led  them  to  suppose  that  in  the  absence  of 
certain  active  light  rays  any  influence  which  would  re- 
sult in  the  depression  of  the  calcium  or  phosphate  ions 
in  the  bodyfluids  with  foe  formation  of  calcium-phos- 
phate ratiQs_iay.orable  for  the  development  of  rickets 
would  ultimately  produce  the  disease. 

Mellanby,1  experimenting  on  puppies,  was  led  to  be- 
lieve that  rickets  was  dependent  upon  calcium,  phos- 
phorus, and  fat-soluble  vitamine  deficiency,  stating  that 
foods  which  were  rich  in  these  substances  prevented 
rickets,  while  those  poor  in  them  apparently  caused  it. 
He  also  believes  that  exercise  is  important  in  the  pre- 
vention of  rickets. 


1  Mellanby,  E. :  Experimental  Rickets,  Med.  Research  Council, 
London,  1921. 


RICKETS.  311 

Hess  and  Unger1  carried  out  a  series  of  experiments 
on  the  relation  of  fat-soluble  A  to  rickets,  but  were  un- 
able to  confirm  his  findings.  They  studied  institutional 
infants  living  under  excellent  hygienic  conditions  with 
good  nursing  and  care,  and  food  adequate  in  caloric  con- 
tent and  containing  sufficient  anti-scorbutic.  Those  fed 
large  amounts  of  milk  (24  to  32  ounces  of  raw  or  pas- 
teurized milk)  developed  rickets  just  as  easily  and  to 
the  same  degree  as  the  infants  receiving  only  %0  per 
cent,  milk  fat.  Those  on  low  fat  showed  no  greater 
signs  of  rickets  than  the  average  baby  in  the  institution, 
even  though  at  the  most  vulnerable  age.  The  babies  fed 
large  amounts  showed  no  symptoms  of  indigestion  which 
might  have  resulted  in  an  inability  to  properly  metabo- 
lize their  diet.  They  conclude  that  the  fat-soluble  vita- 
mine  is  not  the  much  sought  for  anti-rachitic  factor  and 
that  .babies  can  thrive  for  a  long  period  on  a  very  limited 
amount  of ..faL, providing  that  the  diet  is  otherwise  ade- 
quate. They  feel  that  the  infants  must  have  utilized 
enough  fat-soluble  A  vitamine  from  this  large  amount 
of  milk  fat,  even  if  the  vitamine  content  of  the  milk 
might  have  been  small  because  of  possible  deficient  diet 
of  the  cows.  They  state  that  it  is^their  belief  that 
rickets  is  primarily  a  dietetic  disorder  but  that  hygienic 
factorSj_such  ag__simlighff  poor  ventilation^  and  crowded 
quarters  and  infection,  are  important  contributory 
agencies. 

It  is  a  common  clinical  experience  to  find  that  diets 
containing  a  minimum  of  fats  and  salts,  composed  largely 
of  carbohydrates,  which  usually  means  cereals,  result  in 
the  development  of  rickets.  This  poorly  balanced  com- 
bination is  strikingly  seen  in  the  feeding  with  proprie- 
tary infant  foods,  to  which  a  minimum  of  milk  is  to  be 
added.  A  sweetened  condensed  milk  diet  offers  a  good 
example  of  what  may  be  expected  from  overheating, 
ageing,  and  a  low  fat  and  high  sugar  feeding. 


Hess  and  Unger :  Jour.  A.  M.  A.,  Ixxiv,  217,  Jan.  24,  1920. 


312  INFANT  FEEDING. 

The  theory  of  defective  hygienic  conditions  and  do- 
mestication, particularly  in  crowded  cities,  was  first  ex- 
pounded by  von  Hansemann.1  Findlay2  believes  that 
poor  housing  conditions,  lack  of  fresh  air  and  exercise, 
are  important  factors. 

Hess  and  Unger3  were  the  first  to  demonstrate  by 
means  of  the  roentgenograph  that  sunlight  alone  exerts 
a  curative  action  in  rickets.  They  also  pointed  out  the 
possible  role  of  actinic  rays  in  an  interpretation  of  the 
seasonal  variation  in  the  disease  and  expressed  the 
opinion  that  it  is  the  dominant  factor  in  this  incidence. 
They  do  not  imply  the  diet  is  not  of  importance  in  the 
etiology  of  rickets,  but  rather  that  a  hygienic  factor — 
sunlight — also  needs  to  be  taken  into  account.  They 
also  confirmed  the  work  of  Huldschinsky  and  others,4 
to  the  effect  that  the  ultra-violet  rays  from  a  quartz  lamp 
and  other  sources  had  a  similar  curative  value.  Powers 
and  his  co-workers5  demonstrated  the  effect  of  the  ac- 
tion of  light  in  rickets  in  rats  by  a  series  of  experiments. 
The  diet  used  was  the  same  in  all  animals  and  contained 
an  optimal  content  of  calcium  and  was  decidedly  below 
the  optimum  in  its  content  of  phosphorus  and  fat-soluble 
A,  and  in  other  respects  it  was  well  balanced.  The 
experiments  covered  a  period  of  two  months.  The  ani- 
mals which  were  kept  in  sunlight  with  a  daily  average 
of  four  hours  of  exposure,  did  not  develop  rickets  and 
became  sexually  active.  The  control  animals,  which  were 
kept  in  an  ordinary  laboratory,  showed  all  the  gross  and 
microscopic  evidence  of  rickets.  In  the  animals  exposed 
to  sunlight  on  this  poorly  balanced  diet,  while  not  show- 
ing rachitic  changes  in  the  bones,  there  resulted  more 


1  Von  Hansemann :  Berliner  klin.  Woch.,  1906,  20—21. 

2  Findlay :  Brit.  Med.  Jour.  13,  July  4,  1908. 

Glasgow  Med.  Jour.,  89,  268,  May,  1918. 
Med.  Res.  Committee  Report,  20,   1918. 
STTess  and  Unger:  Jour.  A.  M.  A.,  77,  39,  1921. 
—  4  Huldschinsky :  Deutsch.  JVIed.  Wochnschr.,  45,  712,  1919. 

5  Powers,   Park,  Shipley,  McCollum  and  Simmonds :  Jour.  A. 
M.  A.,  78,  159,  1922. 


RICKETS.  313 

delicate  bone  structure  than  in  animals  placed  on  a 
properly  balanced  diet  under  the  same  conditions;  show- 
ing that  while  the  sunshine  completely  prevented  the 
development  of  rickets  it  did  not  entirely  compensate 
for  the  deficiency  of  phosphorus  in  the  diet,  as  regards 
the  growth  and  development  of  the  rat  as  a  whole  \  or 
of  the  skeleton,  but  did  enable  the  organism  to  put  into 
operation  regulatory  mechanisms  which  otherwise  would 
have  been  inoperative  or  ineffective. 

The  infection  theory  as  a  direct  cause  of  rickets  has 
few  followers  except  insofar  as  infection  may  interfere 
with  metabolism. 

The  endocrine  gland  theory.  The  thyroid,  parathy- 
roid, thymus,  and  adrenal  abnormalities  have  each  in 
turn  been  described  as  being  closely  related  to  the  de- 
velopment of  rickets,  but  in  all  probability  the  dysfunc- 
tion described  has  been  secondary  to  the  same  factors 
causing  the  pathological  changes  in  other  tissues. 

From  the  accumulated  data  on  animal  experiments 
and  clinical  studies  the  conclusions  must  be  drawn  that 
the  dietetic  and  hygienic  theories  offer  the  best  solution 
of  the  pathogenesis  of  rickets. 

The  question  of  race  may  predispose  its  development, 
as  may  heredity  in  exceptional  cases. 

The  seasonal  incidence  is  probably  influenced  by  the 
confinement  and  poor  hygiene  during  the  winter  and 
spring  months  and  the  frequency  of  infections  during 
this  period  of  the  year.  In  the  artificially  fed,  the  winter 
feed  of  the  cows  may  be  an  element. 

Chronic  constitutional  and  metabolic  disturbances  may 
act  as  contributory  causes. 

Mineral  metabolism.     Schabad  and  others  have  shown 

(that  the  calcium  and  phosphorus  balance  is  disturbed  in 

trickets,  the  excretion  of  both   phosphorus   and   calcium 

bein     increased  in  the  acute  stage  and 


convalescence!     It  is  certain  that  the  calcium  and  phos- 


314  INFANT  FEEDING. 

phorus  content  of  rachitic  bone  is  much  reduced  from 
the  normal. 

The  following  facts  are  known  regarding  the  metabo- 
lism of  calcium  and  phosphorus:  There  is  practically 
always  a  sufficient  amount  of  calcium  in  the  infant's  food 
to  meet  its  requirements  for  health  and  growth,  although 
a  calcium  dietary  deficiency  may  be  present  in  the  ex- 
clusively breast-fed.  Breast  milk  contains  2  Gm.  of  ash 
per  1000  mils  and  jCX458^Gm.  of  calcium  per  1000  mils. 
Cow's  milk  contains  7.5  Gm.  of  ash  per  1000  mils  and 
1.72  Gm.  of  calcium  per  1000  mils;  thus__the  calcium 
I  content  of  cow's  milk  is  four  times  that  of  human  milk. 
The  calcium  in  the  milk  is  in  organic  combination  al- 
though inorganic  calcium  may  also  be  absorbed  by  the 
body.1 

In  Holt's2  series  of  studies  on  calcium  metabolism, 
healthy  infants  taking  cow's  milk  modifications  absorbed 
0.09  Gm.  of  calcium  oxide  per  kilogram  of  body  weight, 
while  breast-fed  infants  absorbed  0.06  Gm.  per  kilogram. 
Somewhat  older  children,  taking  a  mixed  diet,  absorbed 
0.055  Gm.  per  kilogram.  All  of  these  cases  received  a 
sufficient  calcium  intake.  He  further  states  that  the  in- 
take of  calcium  oxide  should  be  at  least  0.19  Gm.  per 
kilogram  to  insure  the  average  absorption  of  0.09  Gm. 
per  kilogram  in  the  artifically  fed  and  at  least  0.13  per 
kilogram  to  insure  an  absorption  of  0.06  Gm.  per  kilo- 
gram, the  amount  absorbed  by  the  breast-fed.  In  gen- 
eral he  found  that  35  to  55  per  cent,  of  the  calcium  in- 
take was  absorbed.  An  excessive  calcium  intake  did  not 
increase  the  calcium  absorption  as  the  excess  was  ex- 
creted. If  the  intake  of  calcium  oxide  were  very  low, 
less  than  0.10  Gm.  per  kilogram,  the  absorption  of  the 


1  Aschenheim    and    Kaurnheimer :  Monatsch.     f.    Kinderh.    X. 
1911—12,  435. 

2  Holt,  L.  E.,  Courtney,  A.  M.,  and  Fales,  H. :  Amer.  Jour.  Dis. 
of  Children,  Vol.  19,  P.  97,  Feb.  1920  and  p.  201,  March,  1920. 

v- 


RICKETS.  315 

CaO  was  below  the  necessary  requirements,  and  a  nega- 
tive calcium  balance  might  develop.  They  found  the  best 
absorption  of  calcium  obtained  when  the  calcium  intake 
bore  a  definite  relation  to  fat  intake.  McCollum  believes 
that  in  infants  the  reason  that  rickets  develop  is  because 
the  dilution  of  milk  is  such  as  to  destroy  or  alter  the 
proper  mineral  proportion  when  nothing  else  is  added 
to  the  diet. 

Excretion  of  calcium  is  almost  entirely  through  the 
intestines,  especially  the  large  bowel,  only  5  to  10  per 
cent,  being  excreted  by  the  kidneys.1  Children  suffer- 
ing  from  chronic  intestinal  indigestion  show  a  low 
calcium^  absorptiorr 

A  diminished  calcium  retention  (negative  calcium 
balance)  exists  in  the  florid  stage  of  rickets,2  even 
though  the  intake  is  ample.  The  calcium  retention  re- 
turns to  normal  when  the  disease  is  cured,  but  during 
recovery  the  absorption  is  higher  and  the  excretion  in 
the  stools  less  than 'normal.3  Rowland  and  Park4  have 
demonstrated  a  beginning  calcium  deposit  in  the  bones 
of  animals  two  days  after  beginning  the  administration 
of  codliver  oil.  By  the  end  of  the  third  week  after  be- 
ginning the  administration  of  codliver  oil,  calcium  de- 
posits can  be  demonstrated  in  the  cartilages  of  human 
beings  by  means  of  the  roentgenogram. 

In  prematures  there  is  very  low  calcium  retention  dur- 
ing the  first  month  of  life,  according  to  Hamilton.5  This 
is  probably  dependent  on  several  factors,  among  the 
most  important  being  .the  low  mineral  content  of  pre- 
maturely born  infants,  and  the  restricted  intake  of  foods 
with  low  calcium  and  phosphorus  content,  as  is  found 


1  Voit,  E. :  Zeitschr.  f .  Biol.,  1880,  xvi,  55. 

2  Schabad :  Arch,  f .  Kinderh.,  1910,  liii,  380. 

3Holt,  L.  E.,  Courtney,  A.  M.  and  Fales,  H. :  Am.  Jour.  Dis. 
of  Children,  Vol.  19,  p.  97,  Feb.,  1920,  p.  201,  March,  1920. 

4  Report  of  the  32d  Meeting  of  Amer.  Fed.  Soc.  Arch  of  Fed. 
xxxvii,  411,  July,  1920. 

5  Hamilton :  Am.  Jour.    Dis.   of    Children,   Vol.  20,   316,    1920. 


I 


316  INFANT  FEEDING. 

in  breast  milk  and  cow's  milk  in  high  dilutions.  These 
infants  almost  invariably  suffer  from  severe  secondary 
anemias,  dependent  upon  the  same  causes.  Both  rickets 
and  secondary  anemia  are  frequently  prominent  in  this 
class  of  infants  by  the  end  of  the  second  month  of  life. 
Rachitic  premature  infants  also  show  bone  changes  which 
present  a  different  pathological  picture  from  the  later 
rickets  seen  in  full  term  infants,  in  that  the  skull  is 
involved  out  of  proportion  to  the  clinical  findings  in  the 
extremities  and  thorax.  The  result  is  a  megacephalus 
characterized  by  a  large,  round  head  with  prominent 
frontal  and  parietal  eminences  and  open  sutures,  while 
the  changes  in  the  ends  of  the  long  bones  and  costochon- 
dral  junctions  show  only  a  moderate  degree  of  involve- 
ment. 

f  The  average  normal  blood  calcium  content  for  infants 
under  1  year  of  age  is  10  to  11  mg.  per  100  mils  of  serum.1 
Kramer  and  Rowland2  have  demonstrated  that  the  cal- 
cium concentration  in  the  serum  in  normal  children  is 
singularly  constant,  so  that  even  small  deviations  are 

^  regarded  as  diagnostic  of  disorder. 

As  previously  stated,  dependent  upon  the  blood  pic- 
ture, there  are  in  all  probability  two  main  kinds  of 
rickets.  One  is  characterized  by  a  normal  or  nearly 
normal  blood  calcium  and  a  lgvy_blood  phosphorus  f  the 
other  by  a  normal  or  nearly  normal  blood  phosphorus 
but  a  low  blood  calcium.  The  investigations  of  How- 
land  and  Kramer,3  and  of  Kramer,  Tisdall  and  Rowland,4 
on  the  calcium  and  phosphorus  content  of  the  blood 
serum  in  rickets  and  tetany  have  given  suggestive  evi- 
dence in  support  of  this  idea.  These  observers  found 
that  in  children  suffering  from  rickets  alone,  the  phos- 


1  Brown,  A. :  Am.  Jour.  Dis.  of  Children,  Vol.  19,  413,  1920. 

2  Kramer,  B.,  and  Rowland,  J. :  Jour.  Biol.  Chem.,  xliii,  35,  1920. 

3  Rowland,  J.,  and  Kramer,  B. :  Am.  J.  Dis.  of   Children,  22, 
105,  1921. 

4  Kramer,   B.,   Tisdall,   F.,   and   Rowland,  J. :  Am.   J.   Dis.   of 
Children,  22,  431,  1921. 


RICKETS.  317 

Gihorus  of  the  blood  serum  is  low,  and  the  calcium  not 
ar  removed  from  the  normal;  in  children  suffering 
/from  manifest  tetany  complicating  rickets,  on  the  other 
/  hand,  the  calcium  is  low  but  the  phosphorus  often  not 
\far  removed  from  normal. 

Phosphorus  Metabolism.  Phosphorus  is  contained  in 
milk  in  the  following  forms:  inorganic  calcium  phos- 
phate, and  as  organic  in  combination  with  casein,  nuclein, 
lecithin,  etc.  There  is  0.294  to  0.418  Gm.  per  1000  mils 
in  human  milk,  of  which  43.3  per  cent,  is  organic,  and 
there  is  an  average  of  2.437  Gm.  per  1000  mils  in  cow's 
milk,  of  which  46  per  cent,  is  organic. 

Schabad1  states  that  two-thirds  more  of  the  phos- 
phorus is  normally  excreted  by  the  kidneys,  the  rest 
from  the  bowel,  the  proportion  being  80 :20  in  the  breast- 
fed and  60 :40  in  the  artificially  fed.  During  florid  rick- 
ets the  relations  ,  are  65:35  and  40:60  respectively,  and 
there  is  an  absolute  increased  excretion  of  phosphorus. 
As  the  disease  is  arrested  the  proper  proportions  are  re- 
established and  for  a  time  there  is  a  greater  retention 
of  phosphorus  than  normal.  Rowland  and  Kramer2 
have  shown  that  the  blood  phosphate  is  low  in  the  blood 
plasma  of  rachitic  children,  and  that  the  administration 
of  codliver  oil  causes  a  marked  rise.  Hess  and  Gutman3 
have  demonstrated  similar  changes  following  exposure 
to  the  sun's  rays  and  by  use  of  quartz  lamps. 

The  phosphorus  of  the  blood  can  be  increased  by 
feeding  phosphorus  per  mouth.  Marriott,4  worked  with 
artificial  blood,  found  that  by  small  increases  in  the  phos- 
phorus content,  a  precipitate  resembling  in  composition 
the  salts  of  bone  was  formed.  Wegner5  found  that  feed- 


1  Schabad :  Arch,  f .  Kinderh.,  1910,  liv,  83. 

2  Rowland  and  Kramer :  John  Hopkins  Hospital  Bulletin,  May, 
1921,  p.  165. 

3  Hess,  A.  F.,  and  Gutman,  P. :  Proc.  Society  Exper.  Biol.  and 
Med.,  19,  31,  1921. 

4  Report  of   32d.   Meeting  of  Am.   Ped.    Soc.,  Arch,   of   Ped., 
xxxvii,  July,  1920. 

5  Wegner :  Virchow's  Arch.  f.  Path.  Anat.,  1872,  55,  9. 


318  INFANT  FEEDING. 

ing  small  doses  of  phosphorus  to  young,  growing  dogs 
and  cats,  caused  an  increased  new  bone  formation,  espe- 
cially in  the  diaphysis  along  the  epiphyseal  lines.  Adult 
bones  were  not  affected.  Kassowitz1  confirmed  the  above 
work  but  noticed  that  feeding  too  large  a  dose  of  phos- 
phorus caused  osteoporosis.  Phemister2  applied  these 
experiments  to  children  and  noticed  by  roentgen  ray 
studies  that  phosphorus  affected  the  normal  bones  of 
children  as  it  did  Wegner's  animals  and  that  the  ac- 
cumulation of  calcium  and  overproduction  of  .bone  in  the 
metaphysis  continued  for  some  time,  even  after  the  ad- 
ministration of  phosphorus  was  discontinued.  Hes  has 
more  recently  reported  similar  results  in  rachitic  infants. 
Further  Relation  of  Diet  to  Calcium  Metabolism. 
Rowland4  has  demonstrated  that  carbohydrates  in  the 
diet  favor  a  calcium  retention.  Freund5  has  shown  that 
an  excess  of  fat  in  the  diet  may  cause  a  negative  calcium 
balance.  Holt  found  that  the  best  absorption  of  cal- 
cium occurred  when  the  food  contained  from  0.045  to 
0.060  Gm.  of  calcium  oxide  for  every  gram  of  fat  and 
the  fat  intake  was  ample,  not  less  than  4.0  Gm.  per  kilo- 
gram. On  a  mixed  diet  a  slightly  lower  proportion  of 
calcium  oxide  to  fat  was  needed  to  insure  good  absorp- 
tion of  calcium  oxide.  No  constant  relation  between 
calcium  and  fat  excretion  was  found.  Lindberg.0  how- 
ever, demonstrated  that  in  the  breast-fed  a  high  fat  in- 
take (breast  milk  enriched  with  added  breast  milk  fat) 
may  lead  to  at  least  temporary  losses  of  calcium.  This 
increased  fat  intake  was  followed  by  an  increased  fat 


1  Kassowitz :  Ztschr.  f.  Klin.  Med.,  1884. 

2  Phemister,  Effects  of  phosphorus  on  growing  normal  and  dis- 
eased bones ;  Jour.  Am.  Med.  Assn.,  70—1737,  June  8,  1918. 

3  Phemister,  Effects  of  phosphorus  on  growing  normal  and  dis- 
eased bones;  Jour.  Am.  Med.  Assn.,  70—1737,  June  8,  1918. 

4  Rowland  and  Marriott :  Am.  J.  Obstet,  1916,  Ixxiv,  541. 

5  Freund:  Jahrb.  f.  Kinderh.,  1905,  Ixi,  36. 

6  Linberg :  Ztschr.  f.  Kinderh.,  xvi,  90,  1917. 


RICKETS.  319 

excretion.  Hamilton1  suggests  that  the  poor  calcium 
retention  in  prematures  may  be  related  to  the  relatively 
large  excretion  of  fat  as  their  characteristic  feces  are 
rich  in  fats.  Protein  apparently  has  no  influence  on  the 
calcium  retention.2 

Summarizing,  it  may  be  stated  that  rickets  is  a  nutri- 
tional disturbance  especially  affecting  the  osseous,  mus- 
cular, and  nervous  systems,  with  resulting  lesions  due 
to  improper  utilization  of  cajcium  and  phosphorus. 

Pathological  Anatomy.  In  rickets  the  most  charac- 
teristic changes  are  in  the  skeleton.  The  changes  are 
distributed  over  the  entire  osseous  system  and  become 
essentially  manifest  in  those  areas  of  the  most  active 
bone  growth. 

The  following  must  be  emphasized  as  characteristic 
factors  of  the  rachitic  bony  process :  hyperemia  of  the 
bones;  irregular  formation  and  proliferation  of  the  tis- 
sues in  which  normally  osseous  formation  occurs ;  de- 
ficient deposit  of  calcium  in  these  tissues,  and  the  patho- 
logic decalcification  of  bones  that  already  contain  calcium. 

The  normal  production  of  bone  occurs  in  the  peri- 
osteum and  at  the  osteochondral  borders,  and  here  the 
essential  anatomical  factors  of  rickets  are  established. 

The  periosteum  is  for  the  most  part  decidedly  thick- 
ened. The  thickening  is  due  to  a  hyperemic  layer  be- 
tween the  fibrous  periosteal  cover  and  the  bone,  consisting 
of  alternate  porous,  plexus-like  tissue  and  coarse  longi- 
tudinal bands.  Microscopic  investigation  reveals  a  sub- 
stratum, rich  in  cells,  which  is  interrupted  by  medullary 
vascular  spaces. 

Section  of  a  normally  growing  bone  reveals  between 
the  osseous  and  cartilaginous  structures  a  limited  and 
sharply-defined  bluish  zone  of  calcification  several  milli- 
meters in  thickness.  Histologically  the  bone  formation 
appears  about  as  follows:  Cutting  centerward  from  the 


i  Hamilton,  B. :  Am.  Jour.  Dis.  of  Children,  20—316,  Oct.,  1920. 
2Tada:  Monatschr.  f.  Kinderh.,  1905—06,  iv,  118. 


320  INFANT  FEEDING. 

cartilaginous  epiphysis  we  find  that  the  cartilage  cells, 
which  were  at  first  deposited  irregularly,  arrange  them- 
selves in  definite  rows  corresponding  to  the  direction  of 
growth,  and  begin  to  enlarge.  The  intermediary  sub- 
stance of  these  cell  columns  takes  up  lime  salts  and  then 
becomes  the  zone  of  provisional  calcification.  From 
points  of  vascular  ossification  in  these  layers  of  cartil- 
aginous proliferation  capillaries  originate  which  cause 
resorption  of  the  cartilaginous  tissue  and  form  medullary 
spaces,  in  the  walls  of  which,  by  proliferation  of  cells 
introduced  through  the  vessels  (osteoblasts),  true  bony 
tissue  forms  and  soon  becomes  a  compact  structure  by 
deposition  of  calcium  salts. 

In  well-developed  rachitic  bones  these  conditions  are 
essentially  changed.  The  osteochondral  boundary  is 
markedly  widened — to  1  cm.  in  thickness — and  conspicu- 
ously red.  In  contrast  to  the  normal  cartilage  the  end 
is  not  sharp  but  serrated.  As  in  the  normal  bone,  the 
cartilaginous  cells  are  first  arranged  in  rows  and  after- 
wards clump  together,  forming  larger  nests.  The  en- 
largement of  the  cartilage  cells,  however,  is  much  greater. 
The  lines  of  direction  are  less  conspicuous  the  closer  we 
approach  to  the  diaphysis.  The  proliferating  capillary 
branches  permeate  this  "chondroid"  tissue  much  more 
deeply  than  in  the  normal  bone,  so  that  in  place  of  a 
uniform  approximation  of  the  cartilage  columns  and 
medullary  spaces  there  is  a  quite  irregular  interlacing 
of  these  histologic  elements.  Of  essential  importance  in 
rickets  is  the  fact  that  through  the  action  of  osteoblasts 
a  structure  arises  which  resembles  bony  tissue;  this  os- 
teoid  tissue,  however,  as  was  seen  in  the  periosteum,  dif- 
fers micro-chemically  from  true  decalcified  bony  tissue 
and  shows  but  slight  tendency  to  calcification. 

Therefore,  in  the  enchondral  ossification,  there  is  an 
enlargement  of  the  zone  of  transformation,  a  marked 
hyperemia  of  the  same,  as  well  as  the  formation  of  oste- 
oid  tissue  and  delayed  calcification.  The  last  factor  is 


RICKETS.  321 

of  essential  importance  in  rickets.  There  is  a  conspicu- 
ous disproportion  between  the  broad  transitional  zone, 
which  is  ready  for  ossification,  and  the  slight  deposit  of 
calcium  which  is  found  there.  The  consequences  of  this 
is  an  abnormal  softness  at  the  epiphysis  and  a  ready 
separation  of  {he  epiphysis  from  the  diaphysis. 

The  bones  are  markedly  hyperemic,  alike  in  the  peri- 
osteum, in  the  zones  of  ossification,  and  in  the  marrow. 
Through  the  great  proliferation  and  the  deficient  calci- 
fication of  the  periosteum,  as  well  as  from  the  absorp- 
tion of  bone,  they  are  abnormally  soft.  This  gives  rise 
to  the  many  deformities  and  curvatures  of  the  skeleton 
with  which  we  have  become  familiar  from  the  symp- 
tomatology. In  addition  there  may  be  infractions  and 
fractures  which  affect  the  shape  of  the  bones  of  the 
extremities  and  the  clavicle.  A  further  consequence 
which  has  been  mentioned  is  the  softness  and  protuber- 
ance of  the  osteochondral  borders  of  the  long  bones. 
Finally,  there  is  an  irregular  periosteal  deposit  and  by 
softening  processes  in  the  flat  bones  of  the  skull  an  ir- 
regular thickening  and  thinning  is  produced,  the  borders 
of  the  bone  being  thickened,  the  thinness  affecting  prin- 
cipally the  squama  of  the  occipital  bone  and  the  depen- 
dent portions  of  the  parietal  bones,  in  which  probably 
unfavorable  conditions  are  brought  about  by  opposing 
pressure  of  the  brain  and  the  overlying  surface. 

In  this  series  of  bony  changes  all  of  those  anomalies 
of  the  skeleton  may  be  included  which  are  met  with  in 
rickets :  Craniotabes,  the  rosary,  narrowed  pelvis,  and 
finally,  the  curvatures  and  deformities  of  the  thorax  and 
extremities. 

The  changes  which  the  skeleton  shows  after  healing 
of  the  process  are  better  understood.  After  the  zone  of 
proliferation  in  the  osteoid  tissue  is  finally  impregnated 
with  lime  salts  and  has  undergone  ossification,  the  bone 
becomes  thicker,  harder,  distorted,  and  its  surface  beset 
with  rough  edges  and  osteophytes.  This  condition  is 

21 


322  INFANT  FEEDING. 

especially  distinct  in  the  tubular  bones,  which  lose  their 
graceful  contour,  become  heavier,  and  sometimes  retain 
the  shape  which  was  produced  in  the  florid  stage  by 
curvatures  and  infractions.  These  thickenings  also  oc- 
cur in  the  cranial  bones.  The  influence  upon  the  per- 
manent teeth,  the  pelvis  and  the  longitudinal  growth  of 
the  tubular  bones  has  already  been  mentioned. 

A  very  interesting  question,  although  at  this  time  ob- 
scure, is  whether  the  organs  of  the  body,  as  well  as  the 
skeleton,  are  affected  in  a  characteristic  manner  by  the 
rachitic  process.  This  pertains  especially  to  the  brain, 


Fig.  12.— D.  V.  First  stage  of  rickets.  Taken  March  28, 
1921,  before  beginning  of  phosphorized  codliver  oil  therapy. 
The  metaphysis  is  pale  and  hazy.  The  epiphysis  of  the  upper 
end  of  the  shaft  of  the  tibia  is  not  visible  and  at  the  lower 
end  of  the  shaft  is  seen  as  an  indefinite  shadow.  The 
periosteum  appears  as  if  separated  from  the  shaft  by  a  layer 
of  osteoid  tissue. 

the  spleen,  the  blood,  the  liver,  and  perhaps  the  muscles ; 
the  frequent  pathologico-anatomical  findings  in  the  lungs 
and  in  the  heart  are  of  a  secondary  nature,  and  in  the 
digestive  tract  no  regular  form  of  affection  is  noted.  It 
is  true  the  anatomical  findings  in  the  organs  mentioned 
are  not  well-defined,  and  are  by  no  means  characteristic 
of  rickets,  but  the  relatively  common  occurrence  of 
megacephalus  and  enlargement  of  the  spleen  and  of  the 


RICKETS.  323 

liver,  as  well  as  the  rarer  hypertrophy  of  the  brain,  in 
connection  with  the  rachitic  fundamental  process  cannot 
at  once  be  ignored. 

Schmorl,1  in  his  studies  of  healing  rickets,  found  that 
the  initial  deposition  of  calcium  occurring  at  the  cartil- 
age-shaft junction  of  the  long  bones  takes  place  not 
throughout  the  rachitic  metaphysis  or  at  random  in  it 
but  on  the  epiphyseal  side  of  the  metaphysis  in  that  zone 
of  the  proliferative  cartilage  in  which  calcium  deposition 
normally  occurs  and  presumably  would  have  occurred 
had  rickets  never  been  present.  Figs.  12,  13,  14. 


Fig.  13.— D.  V.  Taken  April  26,  1921  after  28  days  treatment 
with  phosphorized  codliver  oil  and  a  well  balanced  diet. 
A  line  of  deposition  of  calcium  salts  is  seen  in  the  proliferat- 
ing zone  of  the  cartilage,  at  right  angles  to  the  long  axis  of 
the  shaft.  This  deposit  is  most  marked  on  the  epiphyseal  side 
of  the  metaphysis.  The  epiphyseal  nucleus  at  the  upper  end 
is  plainly  visible  and  the  one  at  the  lower  end  shows  an  in- 
creased shadow  density. 

Recent  investigations  by  Shipley,  Park,  McCollum, 
Simmonds  and  Parsons,2  on  the  results  following  the 
feeding  of  codliver  oil  to  rachitic  rats,  confirmed  these 


1  Schmorl,  G. :  Ergebn.  d.  inn.  Med.  u.  Kinderh.,  13—  403,  1914. 

2  Shipley,    Park,    McCollum,    Simmonds,    Parsons — Jour.    Biol. 
Chem.,  xlv,  343,  1921. 


324  INFANT  FEEDING. 

findings.  They  found  that  when  the  cartilage  had  be- 
come free  from  calcium  as  the  result  of  the  deficient 
diets,  the  addition  of  codliver  oil  to  the  food  for  a  period 
of  from  two  to  seven  days  was  followed  by  deposition  of 
lime  salts  between  the  cells  of  the  proliferative  zone  of 
cartilage.  The  deposit  of  calcium  salts  is  linear,  the 
width  of  the  line  apparently  depending  on  the  length  of 
time  during  which  the  animal  has  been  fed  codliver  oil. 
The  line  of  deposition  is  at  right  angles  to  the  long  axis 


Fig.  14.— D.  V.  Taken  May  11,  1921,  43  days  after  Fig.  14. 
Shows  an  increased  length  of  the  shaft  due  to  calcium  de- 
posits at  the  epiphyseal  side  of  the  metaphysis.  The  increased 
length  of  the  shaft  at  the  lower  end  is  about  2  mm.  The 
nuclei  at  the  upper  and  lower  ends  of  the  shaft  are  <iow  dis- 
tinctly visible  and  clean  cut.  Calcium  has  been  deposited  in 
the  subperiosteal  osteoid  tissue  and  there  is  no  longer  the  ap- 
pearance of  periosteal  separation. 

of  the  shaft  of  the  bone.  From  the  appearance  of  their 
sections  it  seems  that  very  little  lime  salt  is  laid  down 
in  the  osteoid  tissue  until  calcification  of  the  prolifera- 
tive cartilage  is  complete. 

The  gross  pathology  in  premature  infants  differs  some- 
what   from   that   in    mature    infants.      Megacephalus    is 


RICKETS.  325 

commonly  observed.  Along  with  this  condition  there 
is  a  symmetry  of  the  skull  which  is  produced  mechani- 
cally by  pressure  on  the  infant's  especially  soft  skull  in 
the  first  months  of  life.  The  rachitic  rosary  is  very 
prominent  in  prematures  and  is  explained  on  the  basis 
of  the  constant  respiratory  movements  leading  to  de- 
formities and  marked  enlargement  of  the  epiphyses  of 
the  ribs.  The  chest  is  narrow  and  early  shows  the 
rachitic  grooves.  The  long  bones,  however,  only  show 
moderate  enlargements  of  the  epiphyses  in  prematures, 
although  rachitic  changes  appear  very  early  in  these 
bones.  The  bone  absorption  and  fringing  of  the  epiphy- 
seal  line  with  marked  haziness  at  the  end  of  the  shaft, 
predominate  rather  than  the  increased  proliferation 
which  is  the  rule  in  full  term  rachitic  infants.  Probably 
the  explanation  for  this  is  that  the  rickets  appearing 
very  early  is  terminated  before  the  infant  crawls  or 
walks  and  so  the  compensatory  proliferations  from  pres- 
sure and  weight-bearing  are  not  present.  Consequently 
rickets  may  occur  in  prematures  without  the  epiphyseal 
enlargement  and  curvatures  of  the  long  bones.  The 
histological  examination  shows  the  characteristic  picture, 
however,  even  in  the  absence  of  marked  external  mani- 
festations. 

Symptoms.  The  outstanding-  symptoms  of  well 
developed  rickets  will  not  be  described  here.  It  is,  how- 
ever, very  important  to  be  thoroughly  familiar  with  the 
early  symptoms  of  rickets,  as  in  the  first  stage,  before 
permanent  damage  has  been  done,  it  responds  most 
readily  to  treatment.  The  first  evidences  of  rickets  may 
escape  attention  unless  the  examiner  considers  the  pos- 
sibility of  its  presence  from  the  history.  Fretfulness, 
irritability,  restless  sleep  and  excessive  perspiration. about 
the  head  are  among  the  earliest  signs.  These  children 
are  usually  pallid  and  show  considerable  evidence  of  a 
secondary  anemia.  Constipation  frequently  appears  early 
and  may  alternate  with  diarrhea.  There  is  soon  noted 


326 


INFANT  FEEDING. 


a  more  or  less  evident  backwardness  in  physical  develop- 
ment; the  child  may  be  unable  to  hold  up  its  head  and, 
at  later  age,  to  sit  up  or  stand  as  a  normal  child  would 
at  the  same  age.  (Fig.  15.)  The  muscles  are  flabby, 
the  abdomen  distended  and  tympanic,  and  an  umbilical 
hernia  is  a  frequent  complication.  (Fig.  16.)  As  the 
condition  advances  the  anemia  becomes  more  marked 


Fig.  15. — H.  G.  Colored  infant,  showing  an  extreme  degree 
of  rickets.  The  head,  extremities,  chest  and  abdomen  show 
the  typical  deformities.  A  large  umbilical  hernia  is  present. 

and  there  is  a  tendency  towards  splenic  enlargement. 
Among  the  earliest  changes  in  the  skeleton  is  the  develop- 
ment of  beading  of  the  ribs  at  the  costochondral  junc- 
tions forming  the  socalled  rachitic  rosary.  In  the 
severer  types  this  is  followed  by  a  sinking  in  of  the  ribs 
in  the  axillary  line  and  a  flaring  out  of  the  ribs  below, 
the  latter  being  due  to  the  support  furnished  by  the 


RICKETS. 


327 


Fig.  16.— H.  G.  Same  infant,  showing  the  descending  colon, 
sigmoid  and  rectum  distended  by  a  barium  enema.  The 
megalocolon  and  enormous  sigmoid  account  to  a  large  ex- 
tent for  the  abdominal  enlargement  and  constipation  in  this 
case. 


328  INFANT  FEEDING. 

intra-abdominal  organs.  The  depression  at'  the  costo- 
chondral  junctions,  described  as  Harrison's  Groove,  is 
to  a  large  extent  due  to  the  traction  on  the  chest  wall 
by  the  diaphragm.  The  skull  usually  shows  enlarged 
veins,  and  is  squared  in  front,  flattened  on  top,  and  has 
marked  frontal  and  parietal  eminences.  The  fontanels 
are  late  in  closing,  as  are  the  sutures.  Craniotabes  is 
one  of  the  pathognomonic  findings.  At  the  junction  of 
the  epiphyses  and  diaphyses  nodular  enlargements  be- 
come palpable  in  the  long  bones  and  are  most  easily 


^* 


Fig.  17. — H.  G.  Same  infant,  showing  the  extreme  changes 
of  a  florid  rickets.  The  typical  enlargement  of  the  soft  parts  is 
noticeable  in  the  outline  of  the  wrists.  The  lower  ends  of 
the  shafts  of  the  radius  and  ulna  show  the  typical  cupping 
and  sawtoothed  appearance.  The  epiphyseal  nuclei  are  widely 
separated  from  the  shafts  and  the  nucleus  of  the  radius  is 
displaced  and  fragmented.  Similar  changes  are  seen  in  all 
of  the  metacarpal  bones  and  the  phalanges. 

recognized  at  the  wrists,  knees,  and  ankles.  (Fig.  17.) 
Dentition  is  frequently  delayed  and  irregular.  The 
primary  teeth  are  subject  to  early  decay.  Deformities 
are  common  and  may  develop  in  any  part  of  the  osseous 
system,  most  commonly  involving  the  long  bones,  verte- 
bral column,  and  pelvis,  as  well  as  the  head,  previously 
described.  The  blood  changes  are  not  characteristic, 
usually  being  those  of  a  secondary  anemia,  with  a  marked 


RICKETS.  329 

reduction  in  the  hemoglobin  and  red  blood  corpuscles, 
and  not  infrequently  a  moderate  leucocytosis  is  present. 
The  nervous  phenomena,  secondary  to  rickets,  are  among 
the  most  important  from  a  therapeutic  standpoint  be- 
cause of  their  reaction  to  proper  treatment.  They  in- 
clude all  of  the  findings  described  under  spasmophilia. 

Of  the  greatest  importance  are  the  radiographic  studies 
of  the  first  and  second  early  stages.  These  have  already 
been  described  in  the  discussion  of  the  gross  bony  path- 
ology. These  changes  allow  of  a  diagnosis  often  four 
to  six  weeks  before  the  disease  results  in  sufficient  bone 
changes  to  be  evident  on  physical  examination. 

Radiographic  Diagnosis.  Radiographic  studies  closely 
follow  the  macroscopic  appearance  of  the  bones.  In  the 
first  stage  the  epiphyses  cast  little  or  no  shadow,  while 
the  center  of  ossification  is  small  or  absent  and  at  times 
appears  multiple.  These  epiphyseal  findings  are  easily 
explained  by  the  interspersing  of  cartilage  masses  be- 
tween the  newly  deposited  osseous  tissues,  and  are  visi- 
ble upon  microscopic  examination  of  fresh  bone  sections 
and  often  on  macroscopic  examination.  The  diaphysis 
becomes  frayed  out,  instead  of  clear-cut,  the  periosteum 
thickened,  and  the  joints  appear  hazy. 

In  this  stage  a  wide  separation  of  the  epiphysis  from 
the  diaphysis  is  frequently  noted,  due  to  the  lack  of  bone 
deposit  in  the  proliferating  zone  or  metaphysis.  Multi- 
ple fractures  are  common. 

In  the  second  stage  the  shadow  of  the  epiphysis  be- 
comes more  marked,  and  the  epiphyseal  line  is  more 
ragged  and  irregular.  The  rnetaphysis  is  widened  with 
an  irregular  saw-toothed  appearance  on  the  epiphyseal 
side  and  there  is  also  a  broadening  and  flaring  of  the 
epiphyseal  line  which  is  very  characteristic.  This  con- 
tinues into  the  third  stage,  and  the  space  between  the 
proliferating  zone  and  the  epiphyseal  nucleus  is  lessened 
by  a  distance  corresponding  to  the  new  bone  deposit  and 
epiphyseal  growth.  This  growth  can  be  measured  on  the 


330  INFANT  FEEDING. 

plates.  Further  changes  in  the  second  stage  consist  in 
the  chambering  of  the  interior  of  the  bone,  where  light 
areas  in  the  shaft  indicate  the  absence  of  bone  deposit, 
and  heavier  lines  of  ossification  show  the  irregular  de- 
velopment of  trabeculse.  There  is  usually  a  thickening 
on  the  concave  side  of  the  shaft,  which  is  a  compensatory 
change.  The  second  stage  is  generally  a  period  of  sys- 
temic reaction  to  the  disease,  in  which  signs  of  returning 
ossification  occur  and  when  deformity  begins.  In  the 
third  stage,  the  epiphysis  begins  to  resume  its  normal 
contour  and  homogeneous  shadow  density.  Irregulari- 
ties persist  in  the  marginal  outline,  and  there  is  still  a 
little  mottling  in  the  ossification.  The  lipping  of  the 
diaphyses  has  enlarged  the  bone  ends,  and  there  is  in 
consequence  a  discrepancy  in  breadth  between  the  di- 
ameters of  the  diaphysis  near  the  epiphyseal  line  and  the 
epiphysis. 

These  bony  changes  and  the  softening  of  the  bone 
gives  rise  to  all  the  various  bony  deformities  of  clinical 
rickets. 

Prognosis.  The  disease  is  chronic,  and  lasts  for 
months  or  up  to  the  end  of  the  first  dentition.  Its 
course  is  modified  by  treatment.  Periods  of  latency  and 
exacerbation  depend  on  diet  and  hygiene  and  are  influ- 
enced by  season  and  secondary  infections.  Usually, 
active  symptoms  subside  when  a  mixed  diet  is  given — 
that  is,  at  about  the  end  of  the  first  year. 

Different  parts  of  the  skeletal  system  are  progres- 
sively involved,  recovery  taking  place  in  one  while  an- 
other is  becoming  affected.  In  the  first  six  months  of 
life  craniotabes,  beading  and  enlarged  epiphyses  may  be 
the  only  physical  signs.  Later  on  the  thorax  becomes 
deformed,  and  then  kyphosis  and  curvatures  of  the  bones 
develop.  The  signs  of  improvement  are  diminished 
sweating  and  restlessness,  disappearance  of  craniotabes 
and  anemia,  increasing  muscular  power,  and  improved . 
general  nutrition.  Deformities  slowly  and  steadily  im-  ] 


RICKETS.  331 

prove  except  in  very  bad  cases,  in  which  they  persist  to 
a  variable  degree  throughout  life,  in  the  shape  of  pigeon- 
breast,  Harrison's  groove,  eversions  of  the  costal  arch, 
kyphosis,  pelvic  deformity,  knock-knee,  bow-legs,  and 
flat-foot: 

Rickets  is  never  fatal  per  se,  but  it  reduces  the  resist- 
ing power,  and  is  an  important  cause  of  increased  mor- 
tality from  other  diseases,  especially  catarrhal  affections 
of  the  alimentary  and  respiratory  systems.  Death  may 
also  result  from  spasmophilic  manifestations,  more  es- 
pecially convulsions.  The  thoracic  deformity  retards 
growth  by  interfering  with  efficient  lung  expansion  and 
oxidation.  Impaired  epiphyseal  growth  may  affect 
growth  in  height,  and  the  malnutrition  may  delay  mental 
development.  Rachitic  children  often  talk  late  and  learn 
new  words  slowly. 

Treatment.  In  a  consideration  of  the  treatment  of 
rickets  prime  importance  must  be  placed  upon  a  careful 
study  of  the  previous  diet  and  life  history  of  the  infant. 
First,  in  a  consideration  of  the  preceding  diets,  the  cases 
may  be  classified  into  those  which  have  been  wholly  or 
largely  breast-fed.  In  this  group  the  general  health  of 
the  mother  and  her  diet  must  be  investigated.  The 
quantity  of  her  milk  should  be  estimated.  Unfortunately 
the  quality  can  usually  only  be  judged  by  the  effect  on 
her  offspring.  The  second  group  of  cases  are  those  de- 
pendent upon  cow's  milk  as  the  main  article  in  their 
diet.  In  this  group  the  source  and  quality  of  the  milk 
as  well  as  the  quantity  must  be  considered.  The  diet 
usually  errs  in  the  direction  of  insufficiency,  however, 
an  excess  of  cow's  milk  may  result  in  a  disturbed  meta- 
bolic balance  with  a  secondary  disturbance  in  calcium 
retention.  The  third  group  of  cases  are  those  dependent 
upon  proprietary  infant  foods  which  contain  cow's  milk. 
The  danger  in  feeding  those  containing  cow's  milk  usu- 
|  ally  lies  in  the  fact  that  the  quantity  of  cow's  milk  they 
[contain  is  insufficient,  or  its  chemical  composition  is 


f 

lite 


332  INFANT  FEEDING. 

I  /changed  in  its  preparation,  and  its  vitamine. 

troyed  by  heating  and  ageing.  The  caloric  value  in  this 
class  oFToods  is  largely  dependent  upon  the  carbohydrates 
contained  and  added  while  their  fat  and  protein  is  usually 
low.  The  fourth  group  are  those  fed  on  proprietary 
foods  containing  little  or  no  cow's  milk  and  which  are 
composed  largely  of  dextrinized  cereals  which  have  been 
devitalized  through  long  continued  heating  and  are  dan- 
gerous because  of  a  second  factor,  namely,  the  instruc- 
tion to  feed  them  with  an  insufficient  quantity  of  cow's 
milk  and  other  needed  food  elements. 

Breast   feeding   must   be   encouraged.      The   lactating 
mother's    diet    should    be  rich    in    milk,    eggs,    butter 
and  green  vegetables.     These  may  be  supplemented  by 
cereals,  root  vegetables  and  muscle-meat,  but  it  is  to  be 
mphasized  that  the  latter  group  are  decidedly  inferior 
to  the  former  in  the  furnishing  of  needed  minerals  (es- 
\pecially  calcium  and  phosphorus)    and  vitamines  in  the 
breast  milk. 

If  the  breast  milk  becomes  deficient,  either  qualita- 
tively or  quantitatively,  mixed  feeding  must  be  instituted. 

In  artificially  fed  infants  the  disease  is  usually  present 
during  the  second  quarter  of  the  first  year,  although  it 
may  not  be  clinically  manifest  until  a  much  later  period. 
A  proper  diet  at  any  age  should  contain  sufficient  fat, 
protein,  carbohydrate,  salts  and  vitamines.  In  most  in- 
stances, cow's  milk  must  in  greater  part  furnish  these 
necessary  elements.  The  cow's  milk  should  be  supple- 
mented as  soon  as  possible  by  the  addition  of  fruit  juices 
and  codliver  oil.  Fresh  cereals,  in  the  form  of  well- 
cooked  gruels,  can  usually  be  added  by  the  fourth  month 
of  life  and  fresh  vegetables  in  the  form  of  a  vegetable- 
cereal-meat  soup,  can  be  started  in  the  sixth  month. 

II  Vegetable  purees  may  be  added  by  the  eighth  or  ninth 
"month.     The  vegetables,  whether  contained  in  soup  or 

when  given  as  purees,  should  be  passed  through  a  fine 
sieve.     The  addition  of   fruit  juices,  cereals  and  vege- 


RICKETS.  333 

tables  should  be  considered  in  the  light  of  prophylactic 
treatment  against  rickets.  The  careful  study  of  the 
whole  diet  should  be  undertaken  and  a  generous  diet,  as 
above  outlined,  should  be  instituted  as  routine  in  the 
feeding  of  all  infants. 

Not  infrequently  the  diets  of  cases  developing  rickets 
are  also  low  in  the  anti-scorbutic  element,  making  the 
early  addition  of  fruit  juices  and  cooked  fruits  of  addi- 
tional value.  In  the  formulating  of  the  diet  in  these 
cases,  the  presence  of  the  secondary  anemia  which  so 
commonly  accompanies  rickets  must  be  considered  and 
the  iron  containing  foods  should  be  added  in  sufficient 
quantities.  For  this  purpose  the  green-leafed  vegetables 
and  meat  juices  or  scraped  meat  pulp  are  of  great  value. 
Therefore,  in  rickets  a  varied  diet  may  be  instituted  in 
every  case  as  soon  as  it  can  be  utilized.  However,  the 
new  food  elements  must  be  added  one  at  a  time  and 
subsequent  changes  made  only  after  it  has  been  ascer- 
tained that  the  infant  can  digest  the  previous  diet.  Sud- 
den and  radical  changes  in  the  diet  may  lead  to  serious 
gastro-intestinal  and  systemic  complications. 

Hygienic  Treatment  The  infant  should  receive 
plenty  of  fresh  air  and  sunshine.  The  practical  value 
of  the  direct  action  of  the  sun's  rays  in  the  treatment 
of  rickets  has  been  conclusively  demonstrated.  The 
weather  permitting,  they  should  be  outdoors  for  several 
hours  a  day,  varying  the  period  according  to  the  weather. 

"Mothering"  in  the  form  of  exercise,  handling  and 
light  massage,  are  invaluable  to  all  infants.  This  is 
especially  true  of  infants  in  institutions. 

The  susceptibility  of  rachitic  infants  to  respiratory 
infections  must  be  remembered  and  every  means  em- 
ployed to  prevent  systemic  depression  due  to  exposure  to 
rapid  changes  of  temperature.  Because  of  the  increased 
susceptibility  of  rachitic  children  to  infections,  they 
should  be  protected  as  far  as  possible  from  any  contact 


334  INFANT  FEEDING. 

with  infectious  cases.  Slight  colds  may  result  in  serious 
systemic  infections. 

Sunlight.  Experimental  evidence  showing  the  favor- 
able action  of  sunlight  on  the  mineral  metabolism  was 
furnished  by  Raczynski1  in  1912.  He  showed  that  in 
rickets  a  deposition  of  salt  in  the  bones  may  be  accom- 
plished without  any  addition  or  alteration  in  the  diet. 
He  took  two  puppies  of  the  same  litter,  both  of  which 
were  being  suckled  by  the  mother,  and  kept  one  in  abso- 
lute darkness  and  the  other,  throughout  the  day,  in  sun- 
light. At  the  end  of  a  six  weeks'  period  both  were 
killed.  An  analysis  of  their  bodies  showed  that  the  one 
which  had  been  reared  in  the  sunlight  contained  over  50 
per  cent,  more  calcium  and  25  per  cent,  more  phos- 
phorus than  the  other,  but  that  on  the  contrary,  it  con- 
tained less  than  half  the  quantity  of  chlorin. 

Powers  and  his  co-workers2  in  a  series  of  experiments 
on  rats,  using  a  diet  which  in  ordinary  room-light  gave 
rise  to  a  disease  in  its  essential  features  identical  w^ith 
rickets  as  seen  in  human  beings,  used  a  diet  high  in 
calcium,  low  in  phosphorus  and  insufficiently  supplied 
with  fat-soluble  A.  In  other  respects  it  was  well  conr 
stituted.  All  control  rats  kept  in  room-light  developed 
rickets,  while  rats  exposed  regularly  to  sunlight  on  an 
average  of  four  hours  a  day  remained,  without  excep- 
tion, entirely  free  from  rickets.  The  animals,  however, 
remained  under-sized;  the  bones,  though  completely  cal- 
cified, remained  thin.  These  experiments  lead  them  to 
believe  that  even  in  the  presence  of  a  defective  diet,  the 
sunlight  raises  the  efficiency  of  the  body  cells.  The  fa- 
vorable effect  of  sunlight  in  rickets  has  recently  been 
emphasized  by  Peer.3  He  calls  attention  to  the  marked 
benefit  which  accrues  in  rickets  from  exposure  to  the 


1  Raczynski,  J. :  Compt-Rend.  de  L'Ass'n.,  Internat.  de  Pediat, 
Paris,  1913,  108. 

2  Powers,  Park,  Shipley,  McCollum  and  Simmonds :  J.  A.  M. 
A.,  78,  3,  January,  1922. 

3  Peer,  E. :  Schweiz.  med.  Wchnschr.,  51,  438,  1921. 


RICKETS.  335 

sun's  rays  in  the  Swiss  Alps.  Riedel1  reports  a  series 
of  cases  treated  with  sunlight  on  bright  days  and  supple- 
menting the  treatment  with  a  quartz  lamp  on  sunless 
days,  with  excellent  results. 

Huldschinsky  made  use  of  sunlight  together  with  the 
ultra-violet  rays  in  some  of  his  series,  and  Riedel  relied 
on  treatment  with  sunlight.  Hess  and  Unger2  demon- 
strated, by  means  of  the  roentgen  ray,  that  sunlight  pos- 
sesses a  curative  action  in  rickets  of  human  beings.  They 
exposed  five  infants  with  rickets  to  the  direct  action  of 
sunlight  for  periods  varying  from  one-half  hour  to  sev- 
eral hours  daily,  whenever  the  sunlight  was  available. 
Different  parts  of  the  body  were  in  turn  subjected  to 
the  action  of  the  sun's  rays.  In  one  of  the  cases  the 
patient  was  exposed  to  the  sunlight  only  on  seven  occa- 
sions, for  a  total  period  of  twenty-five  hours.  The  gen- 
eral condition  of  the  infant's  health,  as  well  as  the  dis- 
eased condition  in  the  bones,  was  benefitted. 

Ultra-violet  Rays.  Since  Bucholz,3  in  1904,  reported 
his  good  results  in  the  treatment  of  rickets  by  artificial 
light  and  heat,  by  exposure  to  the  rays  of  a  special  lamp, 
little  attention  has  been  paid  to  this  form  of  therapy 
until  the  publication  of  the  work  of  Huldschinsky,4  in 
1919.  The  latter  made  use  of  the  quartz  lamp.  In 
December,  1918,  Winkler5  reported  the  favorable  effects 
of  treatment  of  rickets  with  the  roentgen  ray.  He  used 
a  medium  soft  tube  at  a  focal  distance  of  about  20  cm. 
The  exposure  did  not  exceed  ninety  seconds  and  was 
repeated  every  other  day.  The  treatment  at  first  was 
directed  against  the  craniotabetic  lesions  of  the  head. 


1  Riedel,  G. :  Munchen  med.  Wchnschr.,  67,  838,  July,  1920. 

2  Hess,  A.  F.  and  Unger,  L.  J. :  Amer.  Jour.  Dis.  of  Children 
Aug.  1921,  186. 

3  Bucholz,   E. :  Verhandlung  der  Gessellschaft   fur   Kinderheil- 
kunde  in  der  Abteilung  fur  Kinderheilkunde  der  76  Versammlung- 
der  Gessellschaft  Deutscher  Naturforscher  und  Aerzte  in  Breslau 
21,  116,  1904. 

4  Huldschinsky,  K. :  Deutsch.  med.  Wchnschr.,  45,  712,  1919. 

5  Winkler,  F. :  Monatschr.  f.  Kiriderh.,  IS,  52<V  Dec.,  1918. 


336  INFANT  FEEDING. 

After  five  or  six  treatments,  he  observed  that  the  sweat- 
ing of  the  head  came  to  an  end  and  sleep  was  improved. 
As  the  treatment  progressed,  laryngospasm  and  the  ten- 
dency to  convulsions  disappeared.  The  craniotabes  van- 
ished, the  teeth  erupted  ^and  the  calcium  deposition  oc- 
curred at  the  end  of  the  long  bones.  In  1920  Putzig1 
used  the  quartz  lamp  in  the  treatment  of  rickets  in  pre- 
mature infants,  with  good  results.  In  1920  Riedel2  and 
in  1921  Erlacher3  reported  further  cures  with  the  use 
of  the  ultra-violet  rays,  and  in  1921  Mengert4  announced 
the  successful  use  of  the  quartz  lamp  as  a  prophylactic 
agent  against  rickets.  He  claims  it  to  be  especially  good 
in  the  prophylactic  treatment  of  prematures.  In  1921, 
Hess  and  Unger5  also  reported  the  cure  of  rickets  by 
means  of  the  ultra-violet  rays.  They  report  a  group 
of  infants,  varying  in  age  from  8  to  21  months,  which 
were  treated  during  the  months  of  February  and  March, 
the  period  of  the  year  when  rickets  is  likely  to  manifest 
its  highest  incidence  and  least  apt  to  decrease  in  severity. 
During  the  period  of  treatment  no  changes  were  made  in 
the  diet.  Marked  improvement  in  the  bones  was  demon- 
strated by  means  of  roentgenograms,  and  the  hemoglobin 
percentage  and  number  of  red  cells  increased  in  every 
instance.  The  infants  were  treated  three  times  a  week 
for  a  period  of  two  months.  The  entire  body  was  ex- 
posed to  the  rays,  at  first  for  a  period  of  about  three 
minutes,  the  length  of  exposure  being  increased  gradu- 
ally  to  twenty  minutes. 

Kramer,  Casparis  and  Howland6  found  that  by  syste- 
matic exposure  to  the  rays  from  the  mercury  vapor  quartz 
lamp  the  inorganic  phosphorus  concentration  of  the 

1  Putzig,  H. :  Therap.  Halbmonatschr.,  8,  234,  April,  1920. 

2  Riedel,  G. :  Munchen  med.  Wchnschr.,  67,  838,  July,  1920. 

3  Erlacher,  P.:  Wien.  klin.  Wchnschr.,  34,  241,  May,  1921. 

4  Mengert,  E. :  Deutsch.  med.  Wchnschr.,  47,  657,  June,  1921 

5  Hess,  A.  F,  and  Unger,  L.  J. :     Ibid,  13. 

6  Kramer,    B.,    Casparis,    H.,    Howland,   J. :  Amer.    J.    Dis.    of 
Children,  xxiv,  20,  1922. 


RICKETS.  337 

serum  of  these  children  which  was  low  (from  2.7  to  3.2 
mg.)  before  the  treatment  was  begun  gradually  increased 
to  a  maximum  of  6  mg.  with  the  appearance  of  calcium  de- 
position in  the  bones.  So  far  as  could  be  judged,  heal- 
ing of  the  bones  following  radiation  occurred  at  about 
the  same  time  as  it  does  after  the  administration  of  cod- 
liver  oil.  The  changes  in  the  phosphorus  concentration 
of  the  serum  were  identical  with  those  observed  after 
codliver-oil  treatment. 

It  is  my  practice  to  begin  with  50  cm.  distance  for 
three  minutes,  gradually  increasing  the  time  of  exposure 
to  twenty  minutes  by  the  end  of  the  second  month.  At 
least  three  treatments  should  be  given  each  week — when 
possible  they  should  be  given  daily.  The  entire  body 
should  be  exposed,  the  ventral  and  dorsal  aspects  being 
radiated  during  alternate  treatments.  The  eyes  must  be 
protected  by  suitable  glasses. 

In  using  the  quartz  lamp  in  practice  I  apply  the  follow- 
ing exposures  as  suggested  by  Gerstenberger : 

1st  Month : 

TOTAL  EXPOSURES  12. 
At  80  cm.  for  5,     7,    9,  11  minutes. 
At  75  cm.  for  7,    9,  11,  13  minutes. 
At  70  cm.  for  9,  11,  13,  15  minutes. 

2nd  Month: 

TOTAL  EXPOSURES  12. 

At  70  cm.  for  15,  17,  19,  20  minutes. 
At  65  cm.  for  15,  17,  19,  20  minutes. 
At  60  cm.  for  15,  17,  19,  20  minutes. 

The  time  and  distance  requirements  should  be  observed 
in  detail  in  order  to  avoid  an  unnecessary  dermatitis  and 
also  to  make  possible  a  rapid  increase  in  exposures. 

If  no  inconvenience  or  discomfort  is  caused  to  patient 
divide  the  time  of  exposure  into  halves — one  for  the  an- 
terior surface  of  the  body  and  one  for  the  posterior 
surface. 

Any  developing  dermatitis  must  be  treated  by  applica- 
tion of  bland  lanolin  ointment. 

22 


338  INFANT  FEEDING. 

In  summarizing  the  curative  value  of  light — sunlight 
and  artificial — we  may  say  with  positiveness  when  either 
one  of  these  or  both  are  made  available  to  a  rachitic 
infant,  the  defense  mechanism  which  has  previously  been 
ineffectual  is  put  in  operation.  Healing  is  frequently 
seen,  even  in  the  absence  of  a  change  in  diet,  and  there- 
fore, in  cases  so  treated  cannot  be  due  to  the  supplying 
of  the  body  with  either  calcium  or  phosphorus  but  must 
be  dependent  upon  the  raising  of  the  potential  of  cellular 
activity  which  results  in  a  more  efficient  utilization  of 
the  salts  which  are  directly  or  indirectly  concerned  with 
ossification  and  calcification.  Both  methods  of  treatment 
result  in  an  increase  in  the  calcium  and  phosphorus  con- 
tent, the  hemoglobin  and  the  number  of  red  cells  in  the 
blood. 

The  quartz  lamp  can  have  only  a  limited  application 
as  a  therapeutic  agent  in  general  practice.  The  greatest 
value  of  the  experimental  researches  with  ultra-violet 
rays  lies  in  the  affirmation  of  the  earlier  good  reports 
with  heliotherapy  and  the  relation  of  certain  light  rays 
to  the  normal  metabolic  processes  of  the  human  organism. 

If  no  other  service  is  rendered  they  should  at  least 
lead  to  the  more  general  recognition  of  the  necessity  of 
sunlight  in  the  promotion  of  body  growth  and  develop- 
ment. This  means  that  good  hygiene  is  essential  to 
health  and  is  of  especial  importance  as  a  prophylactic 
measure  against  rickets  in  young  infants,  and  an  abso- 
lute essential  to  its  cure. 

Medicinal.  Although  there  is  still  much  conjecture 
regarding  the  fundamental  etiology  of  rickets,  yet  some 
pretty  definite  facts  are  known  regarding  the  medicinal 
therapy. 

It  has  been  repeatedly  demonstrated  that  codliver  oil 
will  prevent  rickets  and  increases  the  amount  of  calcium 
and  phosphorus  retention  in  rickets,  although  this  action 
may  be  slow  in  the  florid  stage.  As  mentioned  previ- 
ously, Rowland  and  Park  have  very  recently  demon- 


RICKETS.  339 

strated  anatomically  in  animals  a  beginning  calcium  de- 
posit in  the  bones  two  days  after  beginning  the  adminis- 
tration of  codliver  oil,  and  in  three  weeks  the>  were  able 
to  demonstrate  similar  changes  in  infants  by  means  of 
the  roentgen  rays.  Combining  phosphorus  with  codliver 
oil  makes  it  more  efficacious.  As  previously  stated, 
Phemister,  Wegner  and  Kassowitz  have  shown  that  phos- 
phorus, when  administered  without  codliver  oil,  stimu- 
lates bone  growth  and  increases  the  calcium  deposits  in 
the  healthy  bones  of  normal  growing  children  and  also 
in  those  rachitic.  The  efficacy  of  administering  calcium 
to  rachitic  patients  is  open  to  much  question.  Most  in- 
vestigators believe  it  is  of  no  value  except  possibly  in 
the  case  of  prematures.  Sufficient  calcium  is  taken  with 
the  food,  the  trouble  being  rather  one  of  poor  calcium 
retention.  During  convalescence,  when  the  retention  of 
calcium  is  extreme,  calcium  administration  may  be  of 
assistance.  One  of  the  best  preparations  is  a  10  per 
cent,  tricalcium  phosphate  C.  P.  in  an  emulsion  of  cod- 
liver  oil  U.  S.  P.,  which  makes  a  smooth  suspension  and 
is  readily  taken  by  infants. 

To  be  most  effective  codliver  oil,  with  or  without  phos- 
phorus, should  be  started  early  in  the  artificially  fed  and 
also  the  breast-fed  of  races  or  individuals  showing  a 
tendency  to  development  of  rickets  in  the  offspring.  This 
is  especially  true  of  the  Italian,  Jewish  and  Negro  races. 
Prematures,  even  when  fed  upon  breast  milk,  show  a 
marked  tendency  toward  development  of  rickets,  and 
should  be  placed  upon  codliver  oil  and  phosphorus  treat- 
ments not  later  than  the  second  month.  It  is  our  custom 
to  start  phosphorized  codliver  oil,  gr.  %00  of  phosphorus 
to  one  dram  of  codliver  oil  (0.0003  Gm.  to  each  4  mils), 
in  small  doses,  by  the  end  of  the  sixth  week  in  infants 
artificially  fed  on  heated  milk  mixtures.  At  first  0.3  to 
1.0  mil  (5-15  minims)  is  given  once  or  twice  daily.  The 
dose  is  rapidly  increased  until  by  the  end  of  the  third 
or  fourth  month,  2  to  4  mils  (%  to  1  dram)  are 


340  INFANT  FEEDING. 

given  twice  daily.  Following  the  sixth  month,  4  mils 
(1  dram)  may  be  given  two  or  three  times  daily.  We 
find  in  most  cases  it  is  well  taken  when  given  in  orange 
juice,  the  anti-rachitic  and  anti-scorbutic  combination  be- 
ing an  excellent  one  in  the  artificially  fed.  The  codliver 
oil  therapy  should  be  continued  well  into  the  time  of 
feeding  of  a  general  diet  containing  more  especially  ani- 
mal fats,  cereals  and  vegetables.  The  anemia  must  be 
combated  with  iron  preparations.  (See  Secondary  Ane- 
mia, page  414.) 

Deformities.  Development  of  deformities  of  the  os- 
seous system,  more  especially  of  the  spine  and  long 
bones,  can  to  a  large  extent  be  prevented.  Infants  should 
be  discouraged  from  walking  until  the  bones  are  firm. 
Head  deformities  can  be  lessened  by  changing  the  posi- 
tion in  which  the  infant  sleeps.  Scoliosis  may  be  avoided 
by  preventing  the  child  from  bearing  weight  on  the  spine 
through  early  attempts  at  sitting,  and  improper  holding 
and  carrying  of  the  infant,  bowing  and  distortion  of  the 
legs  by  preventing  crossing  of  the  legs  around  the  pot- 
belly. Coxa  vara  is  due  to  the  weight  of  the  trunk. 
Many  of  the  deformities  can  be  avoided  by  the  institu- 
tion of  the  proper  orthopedic  measures.  Massage  is  of 
great  value  in  strengthening  the  weakened  muscles. 


PART  VI. 

Spasmophilia. 

(Spasmophilic  Diathesis.     Infantile  Tetany.) 


THE  term  spasmophilic  diathesis,  as  applied  in  the 
clinical  sense,  refers  to  a  constitutional  anomaly  charac- 
terized by  a  general  hyperexcitability  and  irritability  of 
the  nervous  system.  The  most  frequent  active  manifes- 
tations are  general  convulsions,  laryngospasms,  spas- 
modic apnea  and  carpopedal  spasm.  Among  the  latent 
manifestations  are  Chvostek's  facial  phenomenon  and 
Trousseau's  sign.  Among  the  most  constant  findings  is 
Erb's  sign,  the  presence  of  hyperexcitability  of  the  pe- 
ripheral nerves,  evidenced  by  reaction  to  the  galvanic 
current. 

Etiology.  Heredity  and  familial  predisposition  have 
in  the  past  been  considered  as  important  factors.  In  the 
light  of  our  present  knowledge  as  to  changes  in  the  body 
chemistry  in  this  condition,  their  relationship  is  open  to 
question;  however,  it  is  our  belief  that  certain  types  of 
infants  show  symptoms  of  an  unstable  nervous  system 
even  from  birth  and  are  therefore  more  likely  to  develop 
active  clinical  manifestations.  To  this  class  of  cases 
belong  the  restless,  nervous  infants  with  a  tendency  to 
pylorospasms  and  repeated  vomiting.  The  colicky  infant 
which  is  often  overfed  to  pacify  it,  thereby  resulting 
in  the  development  of  nutritional  disturbances,  belongs 
to  this  group.  They  are  often  hypersensitive  to  light  and 
sound,  often  precocious,  and  require  much  entertaining 
and  soon  become  little  tyrants,  seemingly  ruling  the 
household.  They  form  bad  habits  readily  and  the  ut- 
most care  must  be  taken  to  train  them  properly  as  to 

(341) 


342  INFANT  FEEDING. 

regular  habits  of  eating  and  sleeping.  Added  to  the 
difficulties  of  these  infants  is  the  presence  of  neurotic 
parents,  who  often  show  little  inclination  to  train  them. 
We  must,  however,  not  make  the  error  of  believing  that 
most  infants  developing  spasmophilia  during  their  in- 
fancy have  this  hereditary  tendency. 

Spasmophilia  has  in  the  past  been  described  as  a  clin- 
ical entity.  In  the  light  of  more  recent  experimental 
and  clinical  facts,  it  must  be  regarded  as  a  symptom- 
complex  without  a  specific  etiology.  Tetany  may  be  pro- 
duced experimentally  by  the  excision  of  the  parathyroid 
glands,  by  the  injection  into  the  blood  stream  of  sodium 
phosphate  or  of  sodium  bicarbonate,  by  diets  high  in 
potassium  and  sodium  phosphate,  and  by  depleting  the 
system  of  necessary  salts.  It  occurs  spontaneously  in 
many  cases  of  rickets.  It  may  be  likened  to  uremia  in 
the  course  of  nephritis. 

Rickets.     As  a  result  of  their  experiments,   Shipley, 
Park,    McCollum  and   Simmonds1   were   led  to   believe 
that  there  are  two  main  kinds  of  rickets.    One  is  charac- 
terized by  a  normal  or  nearly  normal  blood  calcium  and 
,  a  low  blood  phosphorus  (low  phosphorus  rickets);    the 
'  other  by  a  normal  or  nearly  normal   blood  phosphorus 

but  a  low  blood  calcium  (low  calcium  rickets). 
/"  If  the  hypothesis  just  stated  is  correct,  they  believe 
\  the  relation  of  tetany  to  rickets  would  appear  to  be  as 
I  follows :  Tetany  is  essentially  an  expression  on  the  part 
of  the  nervous  tissues  of  an  insufficiency  of  the  calcium 
ion;  rickets  is  essentially  an  expression  on  the  "parf  of 
the  skeleton  of  disturbed  relations  between  the  calcium 
and  phosphate  ions  of  the  body  fluids.  Tetany  is  fre- 
quently associated  with  rickets  because  rickets  is  a  dis- 
ease in  which  the  calcium  ion  in  the  body  tissues  and  fluids 
is  subject  to  variations.  Tetany  may  occur  independent  of 
manifest  rickets.  Since  tetany  may  occur  with  the  low 


1  Shipley,  Park,  McCollum  and  Simmonds :  Am.  Jour.  Dis.  of 
Children,  v,  23,  p.  91,  1922. 


SPASMOPHILIA.  343 

phosphorus  form  of  rickets,  it  does  not  serve  to  -mark  off 

one  form  of  rickets  from  the  other.    Tetany,  however,  is 

'  essentially,  associated  with  the  low  calcium  form  of  rickets 

<and,  for  all  practical  purposes,  the  low  calcium  form  of 

/rickets  is  the  rickets  of  tetany. 

While  occasionally  cases  are  seen  in  which  clinical  evi- 
dence of  rickets  is  not  demonstrable,  these  cases  are  on 
the  whole  exceptional.  On  the  contrary,  many  cases  of 
rickets,  even  very  severe  types,  exist  in  which  tetany 
does  not  supervene. 

Diet.  The  feeding  history,  with  its  associated  nutri- 
tional disturbances,  is  of  great  importance  in  the  inter- 
pretation of  the  clinical  manifestations.  It  is  but  rarely 
seen  in  the  breast-fed,  and  most  frequently  seen  in  the 
infants  fed  upon  proprietary  foods,  more  particularly 
those  who  have  had  repeated  changes  in  their  diet.  Over- 
feeding with  a  diet  composed  almost  exclusively  of  cow's 
milk  frequently  aggravates  the  condition  and  may,  in 
latent  cases,  precipitate  the  active  manifestations  in  all 
probability  due  to  a  disturbance  of  the  salt  metabolism 
by  the  whey  content  of  the  cow's  milk.  One  of  the  most 
striking  phenomena  in  the  treatment  of  these  cases  is 
the  rapid  disappearance  of  all  manifest  signs  when  the 
infants  are  placed  upon  breast  milk,  with  the  reappear- 
ance upon  the  addition  of  relative  excesses  of  whey  or 
large  quantities  of  cow's  milk. 

Nutritional  disturbances  and  various  errors  of  diet 
often  predispose  to  attacks.  These  errors  of  diet  may 
be  overfeeding  (quantitative)  or  improperly  propor- 
tioned diets  (qualitative),  which  sooner  or  later  result 
in  acute  nutritional  disturbances  which  precipitate  the 
clinical  manifestations. 

Premature  infants  evidence  a  marked  predisposition, 
but  in  the  breast-fed  receiving  sufficient  food,  the  mani- 
fest symptoms  occur  exceptionally.  Convulsions,  when 
present  in  the  breast-fed,  usually  follow  acute  nutritional 
disturbances  and  infections.  Not  uncommonly  the  mere 


344  INFANT  FEEDING. 

changing  to  cow's  milk  precipitates  convulsions.  Even 
in  premature  infants  fed  on  human  milk  the  electrical 
irritability  often  is  such  that  C.O.C.  is  less  than  5  milli- 
amperes  at  the  age  of  6  to  10  weeks.  This  electric  hyper- 
irritability  is  most  frequently  seen  during  the  fourth 
month  in  prematures  and  gradually  disappears  during 
the  fifth  to  sixth  month. — Yllpo.1 

The  early  development  of  rickets  in  the  premature 
may  in  greater  part  account  for  the  early  development 
of  spasmophilia  in  these  infants. 

Acute  Infection.  Some  form  of  infection,  although 
slight,  is  frequently  the  precipitating  factor  of  the  acute 
manifestations.  Reinfection  will  aggravate  the  symp- 
toms or  they  may  precipitate  fresh  attacks  in  healed 
cases. 

Vitamines.  The  work  of  Mysenburg2  tends  to  dis- 
prove any  relationship  between  the  vitamines  and  spas- 
mophilia. 

Age.  The  active  manifestations  are  usually  evidenced 
between  the  sixth  month  and  second  year  in  full-term 
infants,  while  in  the  premature  they  may  be  seen  as 
early  as  the  second  to  the  fourth  month. 

Season.  The  most  active  manifestations,  such  as  con- 
vulsions, laryngeal  and  carpopedal  spasms  are  most  com- 
monly seen  during  the  winter  and  early  spring  months. 
The  season  of  highest  instance  in  most  cases  corresponds 
with  that  in  which  rickets  becomes  most  manifest.  Poor 
hygiene,  lack  of  sunlight,  secondary  infections  in  the 
infant,  and,  in  all  probability,  the  diet  of  the  mother, 
or  that  of  the  cows,  are  all  contributing  factors.  The 
convulsions  seen  with  summer  diarrhea  are  more  often 
toxic  or  infectious  in  origin. 

Pathogenesis.  Several  theories  have  been  advanced. 
All  of  these  have  as  a  basis  some  fundamental  disturb- 


1  Yllpo :  Zeitschr.  f.  Kinderh.,  xxiv,  1919,  1. 

2  Mysenburg:  Am.  Jour.  Dis.  of  Children,  V.  20,  p.  206,  Sept., 
1920, 


SPASMOPHILIA.  345 

ance  in  metabolism.  The  most  generally  accepted  has 
been  based  on  experimental  and  clinical  evidence  of  de- 
creased calcium  retention.  More  recently  considerable 
data  has  been  produced  seemingly  pointing  to  increased 
retention  of  the  alkali  phosphates  (K  and  Na),  with  a 
secondary  diminution  of  Ca  salts  as  precipitating  factors. 

Kramer  and  Rowland  found  that  in  children  suffering 
from  rickets  alone,  the  phosphorus  of  the  blood  serum  is 
low,  and  the  calcium  not  far  removed  from  the  normal ; 
in  children  suffering  from  manifest  tetany  complicating 
rickets,  on  the  other  hand,  the  calcium  is  low  but  the 
phosphorus  not  far  removed  from  normal. 

Calcium  Metabolism.  A  calcium  deficiency  in  the 
tissues  has  been  demonstrated  by  numerous  investigators, 
more  especially  in  the  brain  and  blood.  The  earlier  in- 
vestigations on  the  blood,  by  Rowland  and  Marriott,1 
have  more  recently  been  confirmed  by  Kramer,  Tisdall 
and  Rowland.2  They  found  the  calcium  of  the  blood 
serum  to  be  low  in  tetany,  averaging  5.6  milligrams  per 
100  cubic  centimeters  of  serum,  about  half  the  normal. 
Their  lowest  estimation  was  3.5  milligrams  per  100  cubic 
centimeters  of  serum.  The  average  normal  amount  of 
calcium  per  100  cubic  centimeters  in  their  cases  was  be- 
tween 10  and  11  milligrams.  The  latter  group  of 
workers  found  the  concentration  of  the  sodium,  potas- 
sium and  magnesium  in  the  serum  of  the  patients  with 
tetany  is  essentially  normal.  On  the  other  hand  the 
concentration  of  the  calcium  is  regularly  lowered.  Ob- 
viously the  important  factor  in  the  increasing  irritability 
of  the  neuromuscular  mechanism  in  infantile  tetany  is 
the  decrease  in  the  calcium  concentration.  The  stimu- 
lating effect  of  the  sodium  and  potassium  salts  is  un- 
opposed by  the  inhibitory  effect  of  calcium. 

1  Rowland  and   Marriott :  Quarterly  Jour.   Med.,  xi,   1917,   18. 
289. 

2  Kramer,  Tisdall  and  Rowland :  Am.  Jour.  Dis.  of  Children, 
xxii,  431,  1921. 


346  INFANT  FEEDING. 

The  relation  of  calcium  to  the  symptoms  of  spasmo- 
philia  has  been  studied  extensively,  especially  its  influ- 
ence on  the  electric  excitability.  Physiologists  have 
shown  that  certain  mineral  ions  exert  a  specific  effect  on 
muscle  nerve  irritability.  Rosenstern1  and  Sedgwick-' 
reduced  the  electric  irritability  in  spasmophilic  infants 
by  administering  large  doses  of  calcium  by  mouth. 
Loeb's3  findings  indicate  that  Na  and  K  increase  the 
threshold  for  excitation,  while  Ca  and  Mg  tend  to  de- 
crease this.  This  muscle  nerve  irritability  is  the  func- 

Ca  plus  Mg 

tion  of  the  quotient  as  designated  by  Reiss.4 

Na  plus  K, 

Holt5  has  demonstrated  that  in  the  course  of  diarrheal 
attacks  there  is  a  much  greater  loss  of  Na  and  K  than  Ca 
and  Mg  in  the  stools.  Diuresis  and  catharsis  often  cause 
an  improvement  in  the  spasmophilic  symptoms. 

Phosphorus  Metabolism.  Rowland  and  Kramer6  have 
determined  the  inorganic  phosphate  of  the  serum  in  a 
large  series  of  normal  infants.  They  found  the  con- 
centration to  average  5.4  milligrams  per  hundred  cubic 
centimeters,  with  a  minimum  of  4  milligrams  and  a 
maximum  of  7.1  milligrams,  the  higher  values  being 
usually  found  in  the  serum  of  exclusively  breast-fed 
children.  A  determination  of  the  inorganic  phosphorus 
of  the  serum  in  infantile  tetany  revealed  that  in  about 
half  the  cases  the  phosphorus  concentration  was  within 
normal  limits  or  slightly  above  normal.  This  is  in  marked 
contrast  with  cases  of  uncomplicated  rickets,  i.e.,  with- 
out tetany,  in  which  they  found  a  much  reduced  inor- 
ganic phosphate  serum  content.  In  no  case  did  they 


1  Rosenstern :  Jahrb.  f.  Kinderh.  Ixxii,  1910,  154. 

2  Sedgwick,  J.   P.:  St.  Paul,  Med.  Jour.,   1912,  Vol.  xiv,  497, 
519. 

3  Loeb,  J. :  Oppenheimer's  Handbuch  der  Biochemie. 

4  Reiss:  Zeitschr.  f.  Kinderh.,  1911,  iii,  1. 

5  Holt,  Courtney  and  Fales :  Am.  Jour.  Dis.  of  Children,  1915, 
ix,  213. 

6  Rowland,  J.   and  Kramer,   B. :  Am.  Jour.   Dis.  of  Children, 
xxii,  105,  1921. 


SPASMOPHILIA.  347 

find  a  marked  increase  in  the  inorganic  phosphorus  con- 
centration above  the  normal  level.  On  the  whole,  the 
inorganic  phosphorus  of  the  serum  showed  a  consider- 
able variation.  In  a  number  of  cases  there  was  a 
relative  increase  when  compared  with  the  calcium  con- 
centration. The  significance  of  this  relatively  high  phos- 
phate content  in  the  presence  of  decreased  calcium  in 
cases  of  rickets  complicated  by  tetany  is  as  yet  not  clear. 
They  state  that  an  increase  in  the  inorganic  phosphorus 
of  the  serum  alone,  however,  does  not  seem  to  be  re- 
sponsible for  infantile  tetany. 

Binger1  was  able  to  produce  tetany  by  the  intravenous 
injection  of  orthophosphates.  He  found  that  not  in- 
frequently in  conditions  with  a  calcium  deficiency  alone 
tetany  was  absent.  These  authors  state  that  the  reduc- 
tion of  calcium  alone  is  not  sufficient  to  bring  about 
the  symptoms  of  tetany  unless  certain  other  conditions 
are  satisfied.  The  question  as  to  the  nature  of  such 
associated  findings  must  be  answered  by  further  study. 

Jeppsson  and  Klercker,2  in  a  series  of  experiments, 
found  that  by  feeding  of  0.20  Cms.  of  P2O5,'  in  the  form 
of  K  or  Na  diorthophosphate  per  kilogram  body  weight, 
to  the  normal  infant,  and  0.10  to  spasmophilic  infants, 
they  were  able  to  produce  symptoms  similar  to  those 
seen  in  active  spasmophilia  or  to  activate  the  manifesta- 
tions in  latent  cases  (0.20  gram  of  P2O3  represents 
in  alkali  diorthophosphates  0.27  Cms.  of  K2O  and 
0.18  Cms.  of  Na2O  or  0.49  Cms.  of  K2HPO4  and  0.39 
Cms.  of  Na2HPO4).  When  using  the  potassium  salts 
at  times  these  results  were  manifested  in  a  few  hours. 
With  the  sodium  salts  larger  quantities  were  required 
and  often  the  symptoms  were  not  evident  until  after 
two  or  three  days  of  treatment. 

They  believe  that  most  spasmophilic  children  receive 
an  excess  of  alkali  phosphates  in  their  diets,  more  espe- 


1  Binger :  Jour.  Pharmacol.  and  Exper.  Therap.  10,  1917,  105. 

2  Jeppsson  and  Klercker :  Zeitschr.  f.  Kinderh.,  1921,  Vol.  28,  71. 


348  INFANT  FEEDING. 

cially  during  the  first  and  second  year,  with  the  excep- 

!tion  of  the  first  few  months  of  life,  and  that  the  alkali 
phosphate^  play  a  role  in  the  genesis  of  tetany.1 

The  parathyroid  theory  is  to  a  large  extent  based  upon 
the  fact  that  the  physiologic  and  chemical  findings  in 
spasmophilia,  in  infants,  and  parathyroid  tetany,  in  ani- 
mals, are  nearly  identical.  The  histological  evidence  is 
conflicting  and  for  the  most  part  negative.  Accidental 
removal  of  the  parathyroid  gland  in  humans  and  experi- 
mental excision  of  these  glands  in  animals,  have  both 
resulted  in  a  tetany  that  resembles  in  its  clinical  .mani- 
festations the  spasmophilia  of  infants.  Following  the 
animal  experiments  Rowland  and  Marriott2  have  demon- 
strated a  diminution  in  the  calcium  content  of  the  blood. 
These  findings  have  been  verified  by  MacCallum  and 
his  co-workers,3  who  also  found  a  decreased  calcium 

1  content  in  the  brain  and  an  increased  excretion.  They 
believe  that  the  parathyroid  gland  regulates  calcium 
metabolism  and  that  failure  in  its  secretion  results  in 
a  lessened  retention.  Greenwald,4  in  his  experimental 
studies,  found  that  the  phosphorus  excretion  in  the  urine 
of  his  animals  was  greatly  decreased,  to  as  low  as  8  per 
cent,  of  the  normal,  shortly  after  operation  but  after 
development  of  tetany  it  increased  rapidly,  occasionally 
to  an  amount  in  excess  of  the  preoperative  content.  He 
also  found  an  increase  of  the  phosphorus  content  of  the  I 
blood  before  the  appearance  of  tetany.  There  was  also  V 
a  sodium  and  potassium  retention.  He  believes  that  fol-  I 


1  J.  K.  Calvin  and  M.  P.  Borowski :  Amer.  Jour.  Dis.  of  Child- 
ren, 23,  1922,  instituted  a  series  of  investigations  on  our  service 
at  Cook  County  Hospital  to  corroborate  the  Jeppsson  and  Klerc- 
ker  findings.  They  were  unable  to  duplicate  these  results  by  the 
use  of  the  dosage  of  potassium  or  sodium  diorthophosphates  re- 
commended by  these  investigations.  The  observations  were  made- 
on  rachitic  infants  varying  from  6  to  18  months  of  age,  some  of 
whom  had  recently  recovered  from  actively  manifested  spasmo- 
philias. 

-  Rowland  and  Marriott :    Trans.  Amer.  Fed.  Soc.,  28,  200,  1916. 

3  MacCallum  and  Voegtlein:  Jour.  Exper.  Med.,  xi,  118,  1909. 

4  Greenwald,  J. :  Jour.  Biol.  Chem.,  Vol.  14,  370,  1913. 


SPASMOPHILIA.  349 

f  lowing  the  extirpation  of  the  parathyroid  there  is  a  de- 

[  creased  excretion  through  the  kidneys  and  an  abnormal 

J  retention  in  the  tissues  of  the  alkali  phosphates,  which 

/is   followed  by  a  decreased   retention  and  an   increased 

excretion   through   the   kidneys  as   soon  as  the   spasms 

develop. 

There  is,  however,  great  question  as  to  the  relation- 
ship of  parathyroid  dysfunction  and  tetany  in  the  infant. 
Pathological  studies  lead  us  to  believe  that  parathyroid 
lesions  in  infantile  tetany  are  the  great  exception.  Para- 
thyroid lesions  have  been  described  in  patients  who  have 
shown  no  evidences  during  life  of  the  pathognomonic 
findings  of  tetany. 

In  summarizing  the  pathogenesis  we  may  state  that  a 
diminution  of  the  calcium  salts  in  all  probability  is  the 
most  important  factor  in  the  development  of  this  con- 
dition. However,  the  possibility  of  an  absolute  or  rela- 
tive excess  of  the  phosphates,  especially  the  sodium  and 
potassium  salts,  playing  an  important  role  cannot  be  over- 
looked. Abnormal  ratios  in  the  body  salts,  as  in  rickets, 
play  an  important  role.  The  relationship  of  disturbances 
in  parathyroid  functions  to  the  diminution  of  calcium 
tissue  content  must  be  made  the  subject  of  further  study 
before  its  importance  can  be  fixed.  Infections  are  the 
most  frequent  factor  in  precipitating  manifest  symp- 
toms in  the  latent  cases.  The  seasonal  incidence  empha- 
sizes the  importance  of  the  relationship  between  active 
rickets,  infections  and  spasmophilia. 

Symptoms.  The  term  spasmophilic  diathesis  is  used 
in  a  clinical  sense  to  cover  a  symptom  complex,  com- 
prising a  group  of  signs,  any  one  or  all  of  which  are 
pathognomonic  of  the  condition. 

They  consist  of  two  groups,  which  are  best  described 
as  latent  and  active.  Cases  presenting  all  of  the  signs 
to  be  described  are  the  exception  and  in  most  instances 
the  diagnosis  will  be  made  in  the  presence  of  one  or 
more  of  them. 


350 


INFANT  FEEDING. 


The  latent  signs  are  more  apparent  than  the  active 
ones,  and  in  their  most  frequent  sequence  are: 

Erb's  sign,  better  designated  as  increased  electric 
hyperexcitability ;  Chvostek's  facial  phenomenon,  and 
Trousseau's  sign.  Of  the  active  signs  generalized  con- 
vulsions are  the  most  frequently  seen,  while  laryngo- 
spasm,  spastic  apnea  and  carpopedal  spasms  are  of  less 


Fig.  18. — Spasmophilia — Carpo-pedal  spasm.  This  infant 
was  of  the  neuropathic  type  from  birth  and  also  presents 
a  marked  case  of  exudative  diathesis. 

frequent  occurrence.  It,  therefore,  becomes  obvious 
that  many  cases  of  spasmophilia  would  be  overlooked 
were  it  not  for  the  uncovering  of  the  latent  manifesta- 
tions during  the  course  of  a  routine  physical  examina- 
tion. On  the  other  hand,  the  interpretations  of  convul- 
sions must  be  dependent  to  a  large  extent  upon  a  careful 
study  of  the  clinical  history.  Otherwise,  cases  of  spas- 


SPASMOPHILIA.  351 

mophilia  will  be  overlooked  or  a  diagnosis  of  this  con- 
dition made  in  cases  due  to  other  causative  factors. 

Erb's  Sign  (Increased  Electrical  Irritability).  The 
test  is  made  with  a  galvanic  current,  and  for  this  pur- 
pose a  small  battery  made  up  of  dry  cells  answers  the 
purpose  best  .for  the  finer  tests.  However,  there  are 
batteries  with  transformer  attachments  which  can  be 
used  with  ordinary  lighting  current.  A  large,  flat  elec- 
trode (5  cms.)  is  placed  on  the  chest  or  upper  abdomen 
of  the  infant  and  a  small  Stintzing  electrode,  1  or  2  cms. 
in  diameter,  is  placed  over  the  median  nerve,  just  below 
the  elbow,  or  over  the  peroneal  nerve  in  the  outer  part 
of  the  popliteal  space  near  the  head  of  the  fibula.  For 
the  purpose  of  making  the  test  the  opening  contractions 
are  used.1  The  C.  O.  C.  is  usually  first  used  because  of 
its  being  the  easier  of  the  two  opening  contractions  to 
demonstrate,  due  to  the  fact  that  in  normal  infants  under 
2  years  of  age,  approximately  nine  M.  A.  are  required 
to  obtain  a  reaction.  After  completing  this  test  the  pole 
should  be  reversed  and  the  A.  O.  C.  tested.  In  making 
these  tests  the  C.  C.  C.  is  of  little  value  and  the  A.  C.  C. 
is  only  used  for  comparison  with  the  A.  O.  C.  The  test, 
whether  studying  the  C.  O.  C.  or  A.  O.  C.,  should  always 
be  begun  with  a  current  of  sufficient  strength  to  produce 
a  contraction  of  the  muscles  of  the  palm  and  fingers, 
when  the  median  nerve  is  used,  and  the  muscles  of  the 
dorsal  surface  of  the  foot  and  toes  when  the  peroneal 
nerve  is  used.  (Figs.  19  a,  b.) 

The  average  normal  reaction,  under  2  years  of  age, 
will  approximate  the  following: 

C.CC.          A.C.C.          A.O.C          C.O.C. 
2359 


1  For  purposes  of  convenience  the   following  terms  have  been 
abbreviated : 

Cathodal  closing  contraction  C.  C.  C. 

Anodal  closing  contraction A.  C.  C. 

Anodal  opening  contraction A.  O.  C. 

Cathodal  opening  contraction  C.  O.  C. 

Milliamperes    M.  A. 


352 


INFANT  FEEDING. 


In  infants  the  following  electrical  reactions  are  pathog- 
nomonic  of  tetany,  in  the  absence  of  brain  lesions. 

C.  O.  C.  under  5  M.  A. 

A*.  O.  C.  with  less  current  than  that  causing  an  A.  C.  C. 
and  under  5  M.  A.  up  to  the  end  of  the  second  year. 
After  this  age  there  is  a  normal  tendency  for  the  A.  O.  C. 
to  appear  with  less  than  5  M.  A. 

A  C.  O.  C.  with  less  than  2  M.  A.  is  indicative  of  the 


Fig.   19. — Spasmophilia.     A.    Carpal    Spasm.     B.    Pedal    Spasm. 

appearance  of  early  convulsions  and  should  always  be 
considered  as  indication  for  active  treatment. 

Chvostek's  facial  sign  depends  upon  the  hyperexcita- 
bility  of  the  facial  nerve.  Tapping  lightly  with  the 
finger  along  the  course  of  the  nerve,  midway  between 
the  zygoma  and  the  angle  of  the  mouth,  results  in  a  con- 
traction of  the  ala  of  the  nostril,  angle  of  the  mouth,  and 
in  most  cases  the  inner  canthus  of  the  eye  and  the  eye- 
brows. The  appearance  of  a  Chvostek  phenomenon 
under  2  years,  in  the  absence  of  birth  trauma,  indicates 
tetany.  After  3  years  the  Chvostek  phenomenon  is  not 
infrequently  found  in  milder  grades,  in  apparently  nor- 
mal children. 


SPASMOPHILIA. 


353 


Trousseau's  sign,  elicited  by  moderately  compressing 
the  nerves  and  vessels  of  the  arm  midway  between  the 
elbow  and  shoulder  by  the  hand  or  an  elastic  constrictor, 
is  evidenced  when  present  by  the  development  of  a 
carpal  spasm  (obstetrical  hand). 

Ac  tire    Signs.     Carpopcdal   spasms   or  arthrogryposis 


Fig.  20. — Spasmophilia.     Trousseau's   sign.      (Bilateral.) 

(state  of  tetany),  are  seen  clinically  as  tonic  spasms  of 
the  hands  and  feet.  The  fingers  are  usually  flexed  at 
the  metacarpo-phalangeal  joints  and  the  phalanges  ex- 
tended; the  thumbs  are  adducted  almost  to  the  little 
finger;  the  wrist  is  flexed  at  an  acute  angle,  and  the 
whole  hand  drawn  somewhat  to  the  ulnar  side.  If  the 
spasm  is  very  marked  no  motion  is  allowed  at  the  wrist, 
but  movements  at  the  elbow  and  shoulder  are  usually 

23 


354  INFANT  FEEDING. 

normal.  The  feet  are  strongly  extended,  sometimes 
in  the  position  of  typical  equino-varus  and  the  first 
phalanges  of  the  toes  are  flexed.  If  these  conditions 
persist  for  a  long  time,  edema  of  the  dorsal  surfaces 
of  both  hands  and  feet  will  develop.  The  clonic  con- 
tractions at  times  remain  for  hours,  and  even  days,  and 
are  evidently  quite  painful. 

Convulsions  (Eclampsia).  Evidenced  by  loss  of  con- 
sciousness, spasms  of  the  face  and  extremities  at  first 
tonic,  later  clonic.  They  usually  last  only  a  few  min- 
utes— may  or  may  not  recur.  In  exceptional  cases  a 
"status  eclampticus"  develops.  More  commonly,  how- 
ever, in  the  milder  types  the  infant  will  recover  from 
the  individual  attack  quickly  and  without  seeming  after- 
effects, thereby  resembling  the  petit-mal  attacks  of  epi- 
lepsy. Only  in  the  severest  forms  do  they  resemble  the 
grand-mal  attacks  and  only  rarely  is  coma  seen  following 
the  seizure.  Due  to  the  fact  that  spasmophilia  is  most 
frequently  seen  during  the  active  period  of  early  denti- 
tion and  that  many  of  the  cases  show  delayed  dentition 
the  laity  are  inclined  to  ascribe  teething  erroneously  as 
a  cause. 

Laryngismus  Stridulus.  (Inspiratory  laryngospasm.) 
May  occur  without  provocation  or  following  crying  or 
fright.  There  is  an  inspiratory  crow,  due  to  spasmodic 
closure  of  the  larynx,  associated  with  cyanosis  and  it 
may  be  followed  by  convulsions.  The  condition  may 
persist  over  a  period  of  several  weeks  or  until  proper 
treatment  is  instituted. 

Spastic  apnea  or  expiratory  apnea  are  usually  de- 
scribed as  "holding  breath  spells"  and  are  usually  mild 
and  transitory.  They  may  result  in  cardiac  death. 

Course.  The  acute  symptoms  may  last  from  a  few 
days  to  several  weeks.  It  varies  in  most  cases  directly 
with  the  treatment.  Occasionally  a  persistent  type  is 
met  with.  Rickets,  nutritional  disturbances  and  infec- 
tions must  be  overcome. 


SPASMOPHILIA.  355 

Prognosis.  Acute  Attack.  It  should  always  be 
guarded,  as  it  depends  upon  the  underlying  conditions 
which  account  for  the  symptoms.  Convulsions  should 
always  be  considered  as  symptoms  of  grave  importance. 
The  presence  of  thymus  enlargement  has  a  direct  influ- 
ence on  the  mortality  rate. 

Pertussis  should  be  considered  a  serious  complication. 
In  the  majority  of  cases  the  prognosis  is,  on  the  whole, 
good. 

After-life.  While  many  of  these  children  show  no 
after-effects,  a  considerable  number  suffer  from  nerv- 
ous manifestations  in  later  life,  as  headaches,  pavor  noc- 
turnis,  enuresis,  tic,  stuttering,  etc.  Others  show  men- 
tal retardation. 

Treatment.  Dietetic.  Latent  spasmophilia  should  be 
treated  prophylactically  to  prevent  the  development  of 
the  manifest  symptoms.  As  spasmophilia  is  relatively 
rare  in  breast-fed  infants,  the  latent  spasmophilic  should, 
by  preference,  be  fed  human  milk  either  from  its  mother 
or  a  wet-nurse.  In  cases  in  which  the  condition  does 
develop  in  breast-fed  babies,  it  often  disappears  if  the 
infant  is  given  breast  milk  from  another  source  or  a 
mixed  diet.  When  this  is  impossible  the  cow's  milk 
should  be  limited  to  a  pint  a  day  or  it  may  be  replaced 
by  albumin  (eiweiss)  milk  which  has  a  low  whey  con- 
tent. A  cereal  and  vegetable  diet  should  be  instituted 
whenever  the  infant's  age  permits.  Fruit  juices  are  also 
essential.  It  is  often  well  to  keep  the  diet  as  small  in 
quantity  as  is  compatible  with  progress  in  the  child.  A 
temporary  stationary  weight  should  not  be  considered  as 
cause  for  concern.  Sodium  and  potassium  salts  should 
be  avoided.  A  certain  group  of  artificially  fed  infants 
will  do  better  when  cow's  milk,  in  all  forms,  is  greatly 
reduced.  If  the  latent  phenomena  recur  when  cow's 
milk  is  again  increased,  these  infants  should  be  fed  hu- 
man milk  for  a  considerable  time.  In  such  cases  a  mixed 
carbohydrate  diet,  consisting  of  cereals  and  sugars,  to- 


356  INFANT  FEEDING. 

gether  with  vegetable  purees  and  fruit  juices,  should 
be  instituted  whenever  possible. 

They  should  not  be  kept  for  too  long  a  time  on  a 
strict  cereal  diet,  due  to  the  danger  of  development  of 
"flour  injury." 

Medicinal.  Codliver  oil  alone,  or  combined  with  phos- 
phorus, offers  the  best  form  of  medicinal  treatment 
during  the  latent  stage,  however  in  the  presence  of  ac- 
tive manifestations  they  must  be  supplemented  by  other 
forms  of  treatment. 


Fig.  21. — Spasmophilia — Pathological  fractures  of  radius 
and  ulna  with  angular  deformities  following  carpal  spasm. 
(Bilateral.) 

The  calcium  salts  in  the  form  of  chloride,  lactate  or 
bromide,  may  be  used  to  advantage  both  during  the 
active  and  latent  stages.  The  calcium  salts  should  al- 
ways be  prescribed  in  solution  to  prevent  injury  to  the 
mucous  membrane.  Calcium  lactate  or  calcium  chloride 
may  be  administered  in  0.5-1.  Gm.,  three  or  four  times 
daily,  or  calcium  bromide  in  one-half  these  amounts. 
They  are  best  administered  in  the  food  mixtures. 

Convulsions.  An  initial  dose  of  castor  oil  or  magma 
magnesia  is  a  valuable  adjunct  to  the  further  treatment 
in  the  absence  of  marked  gastro-intestinal  irritation.  A 
short  period  of  starvation  diet,  consisting  of  tea  and 


SPASMOPHILIA.  357 

saccharine,  should  be  followed  by  human  milk  where 
possible.  When  it  is  necessary  to  feed  artificially  the 
infant  should  be  kept  for  twenty-four  hours  following 
the  short  starvation  period  on  cereal  gruel  plus  sugar, 
this  to  be  followed  by  low  milk  and  carbohydrate  meals 
or  albumen  milk.  Following  this  the  previously  recom- 
mended dietetic  treatment  may  be  instituted.  It  may  be 
necessary  to  control  the  active  manifestations  by  bro- 
mides per  mouth  and  chloral  hydrate  per  rectum,  and 
when  the  temperature  is  high  saline  enemata,  packs, 
sponging  and  baths  are  indicated.  In  the  presence  of 
repeated  convulsions  we  have  frequently  seen  excellent 
results  following  the  administration  of  10  cubic  centi- 
meters of  an  8  per  cent,  solution  of  magnesium  sulphate, 
hypodermically  daily  for  one,  two,  or  three  days. 

Further  treatment  should  include  the  secondary  ane- 
mia and  not  infrequently  a  change  of  climate  is  of  ad- 
vantage so  that  an  outdoor  life  can  be  lived.  Under  all 
circumstances  a  good  hygienic  and  dietetic  regime  should 
be  instituted.  Heliotherapy  is  of  especial  importance  in 
all  cases  developing  in  the  course  of  rickets. 

Efforts  should  be  directed  toward  the  prevention  of 
all  respiratory  infections,  more  especially  during  the 
winter  and  spring  months. 

Parathyroid  feeding  has  shown  no  results. 


PART  VII. 

Scurvy. 

(Scorbutus,  Barlow's  Disease.) 


SCURVY  is  primarily  a  Deficiency  disease,  due  to  insuf- 
ficiency of  the  antiscorbutic  vitamine.  The  disease  fol- 
lows improper  diet.  The  chief  pathological  changes  are 
noted  in  the  blood  vessels  and  bones.  There  are  two 
distinct  clinical  types:  the  acute  and  the  subacute.  The 
acute  florid  type  presents  the  classical  picture  of  mal- 
nutrition, secondary  anemia  and  hyperesthesia.  Skin, 
mucous  and  serous  membrane,  visceral  and  subperios- 
teal  hemorrhages  develop.  Subacute  or  latent  scurvy  is 
the  most  common  form  of  the  disorder  and  is  character- 
ized by  an  insidious  onset  of  weeks  or  months,  evidenced 
by  lack  of  gain  or  loss  in  weight,  anorexia,  irritability 
and  secondary  anemia.  Later,  hemorrhages  may  occur. 
This  type  is  more  frequently  overlooked,  as  it  does  not 
manifest  pronounced  symptoms.  The  general  improve- 
ment of  these  symptoms  following  antiscorbutic  treat- 
ment confirms  the  diagnosis. 

Etiology.  Congenital  and  inherited  disease  appar- 
ently play  no  part  as  a  causative  factor.  It  occurs  most 
frequently  between  the  ages  of  6  and  15  months,  half 
of  the  cases  occurring  between  the  seventh  and  tenth 
months,  although  occasional  cases  have  been  reported 
in  babies  under  one  month  old.  The  age  of  development 
of  the  disease  depends  upon  the  length  of  time  that  a 
diet  containing  an  insufficient  amount  of  antiscorbutic 
has  been  fed;  even  in  a  decidedly  deficient  diet  a  con- 
siderable time  is  necessary  before  the  disease  becomes 
clinically  manifest.  The  age  at  which  it  most  frequently 
(358) 


SCURVY.  359 

appears  is  that  in  which  artificial  feeding  on  cow's  milk 
and  dextrinized  cereal  diet,  or  other  diets  low  in  anti- 
scorbutics, are  most  commonly  required.  This  age  might 
be  referred  to  as  the  period  of  limited  diet.  Spontane- 
ous cure  in  undiagnosed  cases  is  the  rule  when  the  in- 
fants reach  the  age  of  fresh  cereal,  fruit  and  vegetable 
diet. 

§curyy  is  rare  in  the  breast-fed  infants,  but  does  oc- 
cur. The  health  and  especially  the  diet  of  the  mother 
are  important  predisposing  factors.  McCollum  and 
Simmonds1  have  shown  that  in  lactating  rats  the  vari- 
ous vitamines  cannot  be  synthesized  and  the  content  in 
the  milk  depends  largely  upon  the  amount  eaten  with 
the  food.  Hart,  Steenbock  and  Ellis,2  and  Hess,  Unger 
and  Supplee,3  have  also  shown  this  to  be  true  of  cows 
fed  upon  a  diet  deficient  in  antiscorbutic  vitamine.  Even 
when  the  lactating  mother  receives  a  diet  deficient  in 
vitamines,  the  cellular  substance  of  the  mother's  body 
contains  some,  which  the  catabolic  processes  liber- 
ate, so  that  the  milk  cannot  be  entirely  lacking  in 
vitamines  although  the  content  may  be  too  small  to  pre- 
vent scurvy.  Secondly,  even  though  the  mother's  diet 
is  rich  in  vitamines,  if  she  produces  only  a  small  quan- 
tity of  milk,  the  amount  of  antiscorbutic  vitamine  will 
naturally  be  insufficient  and  thus  predispose  to  scurvy 
in  the  exclusively  breast-fed.  Rickets,  other  diseases 
affecting  the  infant's  metabolism,  and  infection  may  all 
predispose  to  scurvy,  in  the  breast-fed  as  well  as  in 
bottle-fed  infants.  Infection  as  a  precipitating  factor 
will  be  discussed  more  fully  later. 

Most  of  the  scurvy  cases  develop  in  artificially  fed  in- 
fants__As  in  the  breast-fed,  the  absence  of  some  vital 

1  McCollum,  E.  V.  and  Simmonds,  N. :  Amer.  Jour,  of  Phys., 
1918,  46,  275.     McCollum,  E.  V.,  Simmonds,  N.  and   Pitz,  W. : 
Jour.  Biol.  Chem.,  1916,  27,  33. 

2  Hart,  E.  B.,  Steenbock,  H.  and  Ellis,  N.  R. :  Jour.  Biol.  Chem , 
1920,  42,  383. 

3  Hess,  A.,  Unger,   L.   and    Supplee :  Jour.   Biol.   Chem.,    1920, 
48,  229. 


360  INFANT  FEEDING. 

element  in  the  food  is  the  causative  factor.  Starvation 
in  itself  will  not  cause  the  disease,  providing  enough 
antiscorbutic  substance  is  given.  The  time  factor  is  very 
important  in  that  diets  low  in  antiscorbutic  content  must 
be  fed  over  a  prolonged  period  to  cause  the  disease. 
Scurvy  occurs  most  frequently  in  infants  fed  on  pr o- 
prietary  foods.  These  are  composed  largely  of  dex- 
trinized  cereals,  they  are  subjected  to  a  long  process  of 
heating  and  although  milk  is  added,  the  quantities  are 
insufficient  to  meet  the  antiscorbutic  needs.  In  addition, 
the  milk  used  is  usually  subjected  to  prolonged  or  ex- 
cessive heating,  and  in  large  cities  where  pasteurization 
is  compulsory,  frequently  to  a  second  heating  and  con- 
sequent ageing.  Scurvy  is  much  rarer  where  milk  is 
the  principal  article  of  diet.  Cow's  milk  in  itself  is 
relatively  low  in  antiscorbutic.1  2  It  is  estimated  that 
a  pint  of  raw,  fresh  cow's  milk  daily  contains  enough 
antiscorbutic  to  protect  an  infant  from  scurvy,  when 
the  animal  from  which  it  is  obtained  has  been  on  a  well- 
balanced  diet.3  The  winter  diet  of  cattle  which  until 
the  introduction  of  ensilage  was  composed  largely  of 
grains  and  hay,  resulted  in  the  production  of  a  milk 
with  a  lessened  antiscorbutic  content.  This  may  have 
been  a  predisposing  factor  in  the  reported  seasonal  ten- 
dency of  the  disease.  High  dilutions  of  milk  with  a 
lessened  quantitative  content  is  another  factor;  this  is 
comparable  to  the  scant  lactation  in  the  breast-fed. 

Ageing  appears  to  be  a  more_important  factor  than 
|the  heating  of  milk  as  far  as  the  reduction  or  destruc- 
ftion  of  the  antiscorbutic  element  is  concerned.     Hess4 
states  that  boiled  milk  is.  less  liable  to   induce  scurvy 

-1  Moore,  J.  J.  and  Jackson,  L. :  Jour.  A.  M.  A.,  1916. 

2  Chick,   H.   and    Hume,    M. :  Lancet,    1918,   i,    1,    Barnes   and 
Hume,  M. :  Lancet,  1919,  ii,  323.    Cohen  and  Mendel :  Jour.  Biol 
Chem.,  1918,  35,  425. 

3  Hess,  A.,  and  Unger,  L. :  Amer.  Jour.  Dis.  of  Children,  1919, 
17,  221. 

4  Hess,  A. :  Amer.  Jour.  Dis.  of  Children,  1917,  14,  337. 


SCURVY.  361 

than  is  pasteurized  milk,  due,  he  believes,  to  the  fact 
that  the  long-continued  exposure  to  heat  in  pasteuriza- 
tion (145°  F.  for  30  minutes)  has  a  more  destructive 
action  than  a  short  boiling  (212°  F.  for  a  few  minutes). 
His  conclusions  lead  one  to  believe  that  he  considers 
two  factors  of  prime  importance:  first,  ageing  in  itself, 
and,  second,  ageing  plus  the  added  factor  of  heating  to 
a  definite  degree.  He  considers  the  possibility  of  oxida- 
tion during  the  period  of  ageing  as  being  the  destructive 
factor. 

Hess1  further  states  that  when  fresh  cow's  milk  is 
dried  in  a  few  seconds  at  a  temperature  of  240°  F. 
(116°  C),  little  of  its  antiscorbutic  property  is  lost  if 
kept  hermetically  sealed  to  prevent  oxidation.  We  have 
confirmed  this  by  feeding  guinea  pigs  dried  milk  pre- 
pared by  the  Just  Hatmaker  process.2  It  must,  however, 
be  fed  in  sufficient  quantities,  which  is  best  accomplished 
by  feeding  a  concentrated  mixture.  The  exact  value  of 
dried  milk  as  a  complete  diet  for  babies  is  open  to  ques- 
tion, in  the  light  of  our  personal  experiences. 

While  scurvy  occurs  occasionally  in  breast-fed  in- 
fants and  in  those  fed  on  raw  cow's  milk,  it  is  seen  more 
frequently  in  infants  fed  on  boiled,  pasteurized  and 
condensed  milk,  and  in  these  cases,  as  previously  stated, 
two  factors  are  important — prolonged  heating  and  age- 
ing of  the  foods,  either  before  or  after  heating!  Tfie 
same  factors  are  important  in  the  heating  of  proprie- 
tary cereal  foods  plus  limited  quantities  of  cow's  milk. 
In  these  diets  the  vitamines  have  been  destroyed  or 
made  less  active  in  the  cereals  and  are  insufficient  in 
the  milk  to  meet  the  needs  of  the  infant.  A  predispos- 
ing constitutional  factor  in  the  individual  is  not  to  be 
overlooked,  and  probably  accounts  for  the  precipitation 
of  the  disease  in  some  infants  while  others  escape  on 
the  same  diet. 

1  Hess,  A.,  and  Unger,  L. :  Jour.  Biol.  Chem.,  1919,  38,  293. 

2  Moore,  J.  J.,  Hess,  J.  H.,  and  Calvin,  J. :  Unpublished  ex- 
periments. 


362  INFANT  FEEDING. 

Previous  diseases  in  the  artificially  fed,  such  as  rick- 
ets, marasmus  and  other  disturbances  of  metabolism, 
probably  play  a  role  in  predisposing  to  scurvy,  because 
all  of  these  conditions  presuppose  a  poorly  regulated  diet, 
both  quantitatively  and  qualitatively,  which  diet  would 
probably  also  be  unbalanced  in  its  antiscorbutic  element. 

The  relation  of  infections  to  scurvy  has  been  widely 
discussed  recently.  Epidemics  of  scurvy  have  been  re- 
corded in  babies'  institutions.  These  probably  were 
cases  of  latent  or  subacute  scurvy,  in  which  the  acute 
florid  type  was  precipitated  by  a  superimposed  paren- 
teral  infection.  Further,  experience  has  led  us  to  believe 
that  scurvy  predisposes  to  intercurrent  infection,  more 
especially  of  the  skin,  respiratory  and  gastro-intestinal 
tracts.  These  secondary  bacterial  infections  may  cause 
hemorrhagic  lesions  and  the  symptoms  of  the  intestinal 
and  infectious  disorders  become  so  intertwined  as  to  be 
indistinguishable. 

Summarizing,  we  believe  the  evidence  of  a  specific 
organism  as  a  factor  is  absolutely  inconclusive.  How- 
ever, parenteral  infections  may  precipitate  the  develop- 
ment of  scurvy,  or  be  a  factor  in  causing  a  latent  case 
to  become  active.  Enteral  infections,  by  preventing  noY- 
mal  metabolic  exchange,  may  pave  the  way  for  the  de- 
velopment of  scurvy,  as  may  also  be  the  case  in  the 
absorption  of  abnormal  intestinal  substances  which  are 
the  end-products  of  bacterial  activity. 

The  relation  of  ritamines  to  these  so-called  deficiency 
diseases  is  a  much  discussed  subject  and  much  experi- 
mental work  has  been  undertaken  in  this  direction. 
Funk,1  in  1911,  first  called  attention  to  this  relationship. 
II  He  classed  beribgri,  scurvy,  pellagra^  and  rickets_as  de- 
ll ficiency  diseases. 

The  beading  of  the  ribs,  formerly  thnngTif  so  charac- 
teristic ofjadgStsJ_niay— also  occur  in  uncomplicated  cases 

iFunk,  C. :  Lancet,  London,  1911,  ii,  1266.  Die  Vitamine,  Wies- 
baden, 1914. 


SCURVY. 


363 


of  scurvy  in  infants,  and  very  often  the  rosary  quickly 
becomes  less  or  disappears  when  orange  juice  or  other 
antiscorbutic  food  is  given.  This  beading  has  been  ob- 
served in  scorbutic  guinea  pigs  by  Moore  and  Jackson,1 
and  others.  (Fig.  22.)  It  is  truly  scorbutic,  as  it 
shows  the  various  microscopic  appearances  of  scurvy. 
Beading  of  the  ribs  may  also  come  about  as  the  result 
of  a  lack  of  the  water-soluble  vitamine,  although  less 


Fig.  22. — Scurvy  in  guinea-pig  showing  beading  at  the 
costochondral  junctions.     (Jackson  and  Moore.) 

frequently  than  in  scurvy.  This  latter  type  of  beading 
decreases  in  size  when  the  water-soluble  element  is 
added  to  the  diet. — Hess.2  Andrews3  states  that  in 
eighteen  cases  of  beriberi  he  encountered  three  instances 
of  beading  of  the  ribs  at  necropsy,  although  he  had 
never  seen  rickets  at  necropsy  in  the  Philippines.  Darl- 


1  Moore,  J.  J.  and  Jackson,  L. :  Jour.  A.  M.  A.,  1916,  67,  1931. 

2  Hess,  A.  and  Unger,  L. :  Jour.  A.  M.  A.  .1920,  74,  217. 

3  Andrews,  W.  L. :  Philippine  Jour,  of  Science,  1912,  7,  67. 


364  INFANT  FEEDING. 

ing1  states  that  scurvy  resembles  beriberi  in  the  nervous 
involvement,  both  having  increased  knee-jerks,  a  much 
increased  cardio-respiratory  rate,  and  general  and  optic 
nerve  edema.  Pathologically  both  show  enlargement  of 
the  heart  and  fatty  degeneration  of  the  heart  muscle  and 
vagus.  Nichols2  states  that  in  the  tropics  adult  cases 
of  scurvy  often  resemble  pellagra  and  that  they  have 
much  symptomatology  in  common. 

Classification  and  Distribution  of  Vitamines.  McCol- 
lum  and  Davis3  have  demonstrated  two  vitamines,  fat- 
soluble  A  and  water-soluble  B  (antineuritic).  Most  in- 
vestigators now  agree  that  there  is  at  least  a  third  one, 
namely:  water-soluble  C  (antiscorbutic).  These  sub- 
stances are  constituents  of  the  cells  of  both  animal  and 
plant  tissues,  and  the  content  runs  parallel  to  the  cellu- 
lar element  of  the  foodstuffs.  Although  all  natural  food- 
stuffs contain  certain  amounts  of  these  indispensable 
components  of  the  diet,  there  is  a  great  variation  in  the 
relative  and  absolute  amounts  contained.  Thus,  the  best 
sources  of  fat-soluble  A  are  animal  fats,  egg  yolk  fats, 
fish  oils,  milk  fat  and  the  leaves  of  plants ;  water-soluble 
B  in  yeast,  fruit  juices,  vegetables  and  grain  embryos. 
The  leafy  vegetables  and  those  growing  above  the  ground, 
such  as  tomatoes  and  celery,  contain  it  in  larger  pro- 
portions than  the  root  vegetables,  such  as  potatoes,  car- 
rots and  turnips;  water-soluble  C,  the  antiscorbutic  ele- 
ment, is  found  in  practically  all  fresh  animal  and  vege- 
table tissues  and  fruit's  but  to  a  much  greater  extent  in 
the  latter.  It  is  present  in  actively  living  cells,  so  that 
in  general  those  vegetable  tissues  which  contain  rela- 
tively large  numbers  of  actively  respiring  cells  (leafy 
vegetables),  are  richer  in  antiscorbutic  power  than  are 
the  roots  or  tubers.  This  generalization  is  not  without 


1  Darling,  S.  T. :  Jour.  A.  M.  A.,  1914,  63,  1290. 

2  Nichols,  L. :  Jour,  of  Tropical  Med.,  1919,  22,  21. 

3  McCollum,   E.  V.,   and   Davis,   N. :  Jour,   Biol.   Chem.,   1915, 
23,  181. 


SCURVY.  365 

exception.  Different  vegetables  and  fruits  vary  greatly 
in  their  antiscorbutic  potency.  They  differ  widely  also 
in  the  extent  to  which  their  antiscorbutic  value  will  de- 
teriorate under  certain  physical  and  chemical  conditions 
(drying,  alkalinizing,  etc.).  From  the  above  statement 
it  is  apparent  that  the  antiscorbutic  potency  of  food- 
stuffs varies  directly  with  the  quantity  contained. 

Value  of  Various  Foodstuffs.  Considerable  research 
has  been  conducted  in  the  past  few  years  to  determine 
the  antiscorbutic  value  of  various  foodstuffs,  and  the 
effect  of  ageing,  drying,  heating  and  alkalinizing  them. 

Milk  contains  a  moderate  amount  of  all  three  vita- 
mines.  Milk  alone  is  a  complete  food  for  a  number 
;  of  animal  species,  i.e.,  rats  and  swine.  However,  guinea 
pigs  suffer  from  scurvy  on  a  diet  of  oats  and  milk,  even 
1  when  raw  and  fresh,  according  to  McCollum1  and 
Moore,2  which  is  a  difficult  fact  to  explain  on  a  vita- 
mine  hypothesis,  except  that  the  amount  of  milk  which 
a  guinea  pig  will  drink  of  its  own  accord  does  not  con- 
tain a  sufficient  amount  of  antiscorbutic  to  protect  it 
from  scurvy.  Barnes  and  Hume3  state  that  100  to  150 
cubic  centimeters  daily  of  raw  cow's  milk  will  prevent 
scurvy  in  a  guinea  pig,  but  that  such  a  large  daily  intake 
of  milk  causes  digestive  disturbances.  Hess4  states  that 
80  cubic  centimeters  of  fresh,  raw  cow's  milk  will  pre- 
vent the  appearance  of  scurvy  in  guinea  pigs. 

Many  fruits  are  excellent  antiscorbutics.  Orange 
juiceis  one  of  the  best  antiscorbutic  substances.  It  also 
containsthe  water-soluble  B  vitamine,  which  is  essential 
for  growth  and  thus  markedly  stimulates  growth.  It 
should  be  fed  in  considerable  quantities,  varying  from 
15  to  45  cubic  centimeters  daily  for  the  latter  effect.5 

1  McCollum,  E.  V.  and  Pitz,  W. :  Jour.  Biol.  Chem.,  1917,  31, 
229. 

2  Moore,  J.  J.  and  Jackson,  L. :  Jour.  Inf.  Dis.,  1916,  19,  478. 

3  Barnes,  K.  and  Hume,  M.:  Lancet,  London,  1919,  11,  323. 

4  Hess,  A.  and  Unger,  L. :  Ibid. 

5  Byfield,  A.,  and  Daniels,  A.  L. :  Am.  Jour.  Dis.  of  Children, 
1920,  19,  349. 


366  INFANT  FEEDING. 

Orange  juice  is  still  efficient  after  ten  minutes'  boiling: 
it  can  be  dried  rapidly  at  a  low  temperature  and  yet 
contain  a  significant  amount  of  antiscorbutic  substance 
after  three  months.1  This  property  is  present  in  the 
alcoholic  extract  of  the  juice,  but  not  in  the  residue.2 
According  to  Hess,3  artificial  orange  juice  will  not  act 
as  an  antiscorbutic.  The  same  author  found  that  orange 
juice  may  be  filtered,  boiled,  rendered  faintly  alkaline 
and  given  intravenously,  affecting  a  prompt  cure  of 
scurvy.  Harden  and  Zilva4  state  that  when  orange  juice 
is  rendered  slightly  alkaline  and  allowed  to  stand  several 
hours  it  retains  only  a  trace  of  antiscorbutic.  They  con- 
clude that  alkalies  probably  markedly  reduce  the  anti- 
scorbutic property  of  food  in  a  few  hours.  Lemon  juice 
is  about  as  effective  as  orange  juice  but  not  as  readily 
taken  by  infants.  Fresh  limes  have  only  one-fourth  the 
power  of  fresh  lemons,  while  preserved  limes  have  no 
antiscorbutic  power.5  Grapes6  have  only  about  one- 
+,enth  the  antiscorbutic  power  of  oranges,  and  bananas 
and  apples  also  are  poor  in  it.3  Prunes  have  no  value 
as  antiscorbutic.2 

Raw,  fresh  tomatoes  are  jvery  efficient  antiscorbutics 
and  in  contrast  to  some  of  the  other  vegetables  can  be 
dried  rapidly  or  canned  without  losing  much  of  this 
potency.  Hess7  found  that  one  to  four  ounces  daily  of 
strained  canned  tomatoes  will  protect  an  infant  from 
scurvy.  Tomatoes  are  also  rich  in  the  water-soluble  B 
and  the  fat-soluble  A  vitamine,  according  to  Osborne 
and  Mendel.8  Thus,  this  vegetable  contains  all  three 


1  Givens,  M.  H.,   and  McClugage,   H.   B. :  Am.  Jour.   Dis.  of 
Children,  1919,  18,  30. 

2  Hess,  A.,  and  Unger,  L. :  Jour.  Biol.  Chem.,  1918,  35,  479—487. 

3  Hess,  A.,  and  Unger,  L. :  Am.  Jour.  Dis.  of  Children,   1919, 
17,  221. 

4  Harden,  A.,  and  Zilva,  S.  S. :  Lancet,  1918,  11,  320. 
s  Chick,  H.:  Lancet,  1918,  11,  735. 

6  Chick,  H.,  and  Rhodes,  M. :  Lancet,  1918,  11,  774. 

7  Hess,  A.,  and  Unger,  L. :  Jour.  Biol.  Chem.,  1919. 

8  Osborne  and  Mendel :  Jour.  Biol.  Chem.,  1919.    Ibid,  1920. 


SCURVY.  367 

vitamines.     Canned  tomatoes  are  a  valuable  antiscorbutic 
for  institutional  use,  less  practical  in  private  practice. 

Potatoes  are  not  especially  rich  in  this  element  but 
because  of  the  large  quantity  consumed  by  the  popula- 
tion, these  tubers  afford  a  protection  against  scurvy,  al- 
though much  smaller  quantities  of  the  more  potent 
orange  juice  would  suffice. 

Specificity  of   Vitamines.     Yeast^  which  contains  the 
water-soluble   B,   whnphrTs'a   specific   for  beriberi,   has 
practically  no  effect  on  scurvy  or  rickets,  although  it  does 
stimulate  growth.1      By  field2    states   that   orange   juice, 
when  deprived  of  its  water-soluble  B,  still  prevents  and 
cures  scurvy,  but  does  not  stimulate  growth,  which  it 
j  does,  however,  when  water-soluble  B  is  left  intact,  if 
!  large  enough  quantities  are  given  (about  45  cubic  centi- 
|  meters   a  day).      Although   orange   juice  prevents_and 
I  curesjcjicyy,  it  has  practically  no  effect  on  rickets.3    Cod- 
/  liver  oil,  which  contains  the  fat-soluble  vitamine  in  large 
.  /  amounts,  prevents  and  cures  rickets  in  the  presence  of  a 
/    sufficient   quantity   of   the  phosphorus  ion,   but   has  no 
effect:    on    scurvy    or    beriberi.      McCollum    and    Pitz4 
showed  that  oats,  when   fed  with  fats  and  salts,   were 
sufficient   for  proper  growth  and  development  in   rats, 
and  concluded  that  thus  oats  contained  sufficient  water- 
soluble    vitamine.      However,   guinea   pigs   suffer    from 
scurvy  when  fed  only  oats,  which  again  shows  that  the 
absence  of  water-soluble  vitamine  is  not  responsible  for 

scurvy. 

Pathological  Anatomy.  Two  theories  have  received 
recognition  regarding  the  underlying  factors  influencing 
the  development  of  the  pathological  changes. 


i  Hess,  A. :  Am.  Jour.  Dis.  of  Children,  1917,  13,  98. 

a  Byfield,  A.  H.,  and  Daniels,  A. :  Am.  Jour.  Dis.  of  Children, 
1920,  19,  349. 

a  Mellanby,  E. :  Lancet,  London,  1919,  1,  407. 

4  McCollum,  E.  V.,  Simmonds  and  Pitz,  W. :  Jour.  Biol.  Chem., 
1917,  29. 


368  INFANT  FEEDING. 

The  first  regards  the  changes  in  the  bone  marrow  as 
the  primary  factor  with  resulting  interference  with  the 
function  of  the  hematopoietic  system. 

The  second  suggests  primary  blood-vessel  changes  and 
classifies  it  essentially  as  a  hemorrhagic  disease,  with- 
out important  primary  blood  changes,  and  assumes  that 
the  same  causative  factors  are  responsible  for  the  blood- 
vessel and  bone  marrow  changes. 

The   most  prominent  pathological  manifestations   are 


Fig.  23. — Scurvy  showing  lateral  displacement  of  the 
metaphysis  of  both  the  upper  and  lower  ends  of  the  tibia  and 
fibula.  A  similar  displacement  was  present  in  practically  all 
of  the  long  bones.  A  subperiosteal  hemorrhage  is  seen  along 
the  outer  surface  of  the  tibia  which  shows  beginning  cal- 
cification. In  the  process  of  healing  in  this  infant  that  part 
of  the  metaphysis  extending  beyond  the  line  of  the  shaft  was 
completely  absorbed  in  each  instance  and  the  bone  took  on  a 
normal  development  in  the  direct  line  of  the  shaft.  The 
"white  line  of  Fraenkel"  in  this  positive  appears  as  a  dark 
shadow,  above  this  a  rarified  area  is  seen. 

found  at  the  seat  of  most  active  bone  growth,  as  at 
epiphyseal  endsj)f  tJTp_«thaftg  of  jjig^  long  bones,  the  ends 
of  the  ribs  and  the  skull,  due  to  changes  in  all  of  the 


SCURVY.  369 

bone  structures.  A  failure  of  the  integrity  of  the  epi- 
thelium of  the  blood-vessels  is  the  underlying  factor  in 
the  generalized  hemorrhagic  manifestations  in  the  sub- 
periosteal  tissues,  the  gums,  skin  and  the  hematuria. 

The  gross  pathological  findings  in  a  case  of  acute 
scurvy  are  characteristically  typical,  especially  in  the  long 
bones.  Grossly,  there  usually  are  large  or  small  sub- 


Fig.  24. — Scurvy.  Hemorrhage  into  both  knee  joints  with 
displacement  of  left  epiphyseal  nucleus.  Also  showing  white 
line. 

periosteal  hemorrhages,  most  frequently  found  along  the 
shafts  and  distal  ends  of  the  long  bones  of  the  lower 
extremities.  The  periosteum  of  the  long  bones  is  con- 
gested and  swollen.  Inflammatory  changes  rarely  occur 
and  there  is  no  small  round  cell  or  leucocytic  infiltration. 
Extensive  hemorrhage  may  invade  the  soft  tissue  fol- 
lowing rupture  of  the  periosteum.  In  old  hemorrhages 
calcification  of  the  elevated  periosteum  may  be  present 

21 


370  INFANT  FEEDING. 

and  fractures  are  not  uncommon.  Due  to  the  rarefac- 
tion of  the  cortex,  transverse  fractures  either  single  or 
multiple  may  be  present,  due  to  muscle  action,  trauma, 
attempts  at  sitting,  standing  or  falling.  Lateral  displace- 
ment of  the  metaphyses  may  result  from  trauma,  tor- 
sion or  hemorrhage.  (Fig.  23.)  Less  frequently  the 
epiphyses  may  be  dislocated  through  intracapsular 
hemorrhage.  (Fig.  24.) 

Changes  similar  to  those  seen  at  the  ends  of  the  long1 
bones  are  noted  at  the  anterior  ends  of  the  ribs  with 
resulting  beading.  Subperiosteal  hemorrhages  are  not 
uncommon  over  the  skull  and  more  especially  in  the  or- 
bits resulting  in  exophthalmos.  The  latter  may  follow 
prolonged  crying.  The  affection  of  the  gums  is  due  to 
the  pressure  exerted  upon  the  mucous  membrane  by  the 
teeth  in  dentition  and  also  by  external  trauma  as  in  bit- 
ing. The  latter  more  commonly  results  in  hemorrhages 
in  the  upper  jaw. 

On  sectioning  the  bone,  the  cortex  is  seen  to  be  ex- 
ceedingly thin  and  brittle,  the  trabeculae  being  thin  and 
reduced  in  number.  The  marrow  at  the  ends  of  the 
long  bones  is  yellow  and  gelatinous  instead  of  red. 

Microscopic  changes,  as  seen  in  long  bones,  are  most 
characteristically  seen  in  the  marrow.  The  bone  marrow 
is  poor  in  cellular  elements,  the  connective  tissue  frame- 
work increases  at  the  expense  of  the  myeloid  cells  and 
blood-vessels.  Hemorrhages  are  usually  present  in  the 
marrow. 

The  thin  and  fragile  bone  and  poorly  developed  tra- 
beculae are  considered  to  be  due  to  imperfect  function- 
ing of  the  osteoblasts,  which  are  reduced  in  number  and 
appear  smaller  than  normal.  There  is  not  an  excess  of 
osteoclasts,  consequently  normal  resorption  of  bone  oc- 
curs with  diminished  regeneration. 

The  gross  changes  found  in  the  heart  in  severe  cases 
of  scurvy  usually  consist  in  right-sided  hypertrophy  and 
fatty  degeneration  of  the  heart  muscles.  Occasionally 


SCURVY. 


371 


an  increased  quantity  of  fluid  is  noted  in  the  pericardial 
sac.  There  are  no  characteristic  lesions  of  the  valves 
secondary  to  scurvy.  Jackson'  and  Moore1  found  a 
marked  thinning  of  the  walls  of  the  blood-vessels  in  their 
experimental  animals  and  not  infrequently  thrombosis 
of  the  veins  was  noted.  No  constant  lesions  of  the 
blood  vessels  in  human  scurvy  have  been  described.  In 
all  probability  hemorrhage  occurs  by  diapedesis.  Hess2 
believes  that  a  weakness  of  the  vessel  walls  exists,  as 


Fig.  25. — Scurvy.  Showing  fraying  of  the  lower  ends  of 
the  tibia  and  fibula.  There  is  also  a  large  hemorrhage  about 
the  tibia  in  this  illustration  whch  casts  a  very  hazy  shadow. 
This  hemorrhage  is  24  hours  old  and  followed  trauma  due 
to  compression  of  the  soft  parts  during  the  removal  of  blood 
from  the  heel  for  a  Wassermann  test. 

demonstrated  by  the  "capillary  resistance  test,"  which 
consists  in  applying  a  tourniquet  to  the  upper  arm,  thus 
subjecting  the  vessel  walls  to  additional  strain,  generally 
causing  the  appearance  of  numerous  petechise  on  the 
forearm.  Following  the  trauma  caused  in  taking  blood 
from  the  heel  for  a  Wassermann  test,  a  massive  hemor- 


1  Jackson,  L.  and  Moore,  J.  J. :  Jour.  Infect.  Dis.,  1916,  19,  478. 

2  Hess.  A.:  Jour.  A.  M.  A.,  1921,  76,  694. 


372  INFANT  FEEDING. 

rhage  occurred  into  the  soft  tissues  of  the  leg  and  foot 
in  one  of  the  author's  cases.     (Fig.  25.) 

Hess  and  Fish,1  studying  the  blood  in  scurvy,  found 
the  coagulation  time  to  be  normal  or  only  slightly  in- 
creased. No  deficiency  of  blood  platelets  or  calcium  or 
excess  of  antithrombin  could  be  demonstrated.  During 
the  late  war,  scorbutic  patients  operated  upon  showed 
no  particular  tendency  to  hemorrhages. 

The  respiratory  tract  usually  shows  no  typical  changes 
other  than  congestion  and  subserous  hemorrhages.  How- 
ever, in  some  of  the  fatal  cases  secondary  pneumonia, 
infarcts  and  a  generalized  edema  may  be  present.  The 
alimentary  tract  beside  the  swollen  gums,  which  are  usu- 
ally the  seat  of  more  or  less  intense  hemorrhage  and  not 
infrequently  necrosis,  shows  no  constant  changes  in  the 
moderate  types.  In  the  severer  forms  hemorrhage  may 
occur  from  any  region  of  the  stomach  or  the  intestinal 
tract.  The  solitary  follicles  and  Peyer's  patches  are 
usually  infiltrated  and  may  be  ulcerated.  The  spleen  is 
usually  moderately  enlarged  and  congested,  as  is  also  the 
liver.  The  latter  may  also  be  the  seat  of  cloudy  swell- 
ing and  fatty  degeneration;  similar  changes  are  usually 
present  in  the  kidneys.  The  most  frequent  changes  in 
the  nervous  system  are  seen  in  the  peripheral  nerves, 
hemorrhage  into  the  nerve  sheath  being  the  most  com- 
mon. Hemorrhages  are  not  uncommon  in  the  brain  sub- 
stances and  pachymeningitis  hemorrhagica  interna  have 
been  described  repeatedly. 

The  lymph  nodes  draining  areas  of  hemorrhage  are 
enlarged.  In  guinea  pigs  McCarrison2  noted  frequent 
hemorrhages  into  the  adrenals,  greatly  enlarging  them, 
especially  the  medullary  portion  with  degeneration  of  the 
cells  in  both  cortex  and  medulla.  The  adrenalin  content 
is  much  decreased.  These  findings  have  not  been  noted 
in  human  scurvy. 

1  Hess,  A.,  and  Fish,  M. :  Amer.  Jour.  Dis.  of  Children,  1914,  8, 
386. 

2  McCarrison,  R. :  Oxford  University  Press,  New  York,  1921. 


1 


Fig.  26. — Scurvy.  Typical  lesions  of  the  gums,  with  hem- 
orrhage at  the  free  edge  of  the  gums  of  the  incisor 
teeth. 


SCURVY.  373 

Symptoms.  In  the  discussion  of  the  symptoms  of 
scurvy  the  acute  and  subacute  types  must  be  considered, 
and  it  must  be  remembered  that  the  mild  and  severe 
forms  of  each  of  these  will  present  varied  clinical  pic- 
tures. Due  to  the  fact  that  the  symptoms  develop  fol- 
lowing a  prolonged  use  of  an  insufficient  diet,  a  second- 
ary anemia,  usually  associated  with  more  or  less  marked 
hemorrhages  and  bone  changes,  is  found  in  infants  show- 
ing other  evidences  of  malnutrition.  These  may  be  the 
only  clinical  evidence  of  the  disease  in  its  mildest  form. 
The  typical  acute  case  of  severer  type,  after  a  more  or 
less  prolonged  period  of  inanition,  gives  evidence  of  dis- 
comfort on  being  handled  and  shows  a  tendency  to  as- 
sume a  flexed  position  of  extremities.  Tenderness  on 
palpation  of  the  limbs  is  noted  and  the  infant  shows  a 
tendency  to  refrain  from  voluntary  motion.  These 
changes  are  most  frequently  noted  in  the  lower  extremi- 
ties. Palpable  and  visible  swelling  along  the  shafts  may 
develop,  although  they  are  not  constant  findings.  When 
present  they  are  the  result  of  the  subperiosteal  hemor- 
rhages. Less  frequently  these  hemorrhages  are  noted 
in  the  epiphyseal  regions  but  usually  extend  some  dis- 
tance along  the  shaft  of  the  bone  which  tends  to  dis- 
tinguish them  from  acute  inflammatory  joint  conditions. 
Rare  are  the  hemorrhages  into  the  joints  themselves,  al- 
though they  may  occur.  These  may  result  in  epiphyseal 
displacement.  Among  the  rare  lesions  lateral  displace- 
ment of  the  proliferating  zones  may  exist.  While  swell- 
ing and  discoloration  of  the  gums  is  one  of  the  most 
constant  features,  hemorrhage  is  not  always  visible.  The 
typical  lesions  of  the  gums  consist  of  a  red  or  purple 
discoloration  at  the  free  edge  of  the  gums  of  the  incisor 
teeth.  (Fig.  26.)  This  may  exist  on  the  posterior 
edge  behind  the  teeth  and  not  be  present  anteriorly. 
Hemorrhage  in  the  peridental  membrane,  resulting  in 
swollen  and  edematous  gums,  may  be  present  before 
eruption  of  the  teeth.  Very  rarely  the  gums  may  be 


374  INFANT  FEEDING. 

markedly  affected  when  there  is  no  other  obvious  symp- 
tom of  scurvy  excepting  malnutrition  and  secondary 
anemia.  Not  infrequently  the  incisor  teeth  become 
loosened  and  are  lost.  Palatal  hemorrhage,  most  fre- 
quently seen  over  the  middle  part  of  the  vault  of  the 
hard  palate,  should  be  looked  for.  Petechial  and  ecchy- 
motic  hemorrhages  may  occur  spontaneously  in  the  skin 
but  are  more  exceptional  findings  in  the  milder  types 
unless  secondary  to  trauma;  more  frequent  are  the  or- 
bital hemorrhages  resulting  in  a  discoloration  about  the 
eye  and  hemorrhages  into  the  conjunctiva.  Occasionally 
a  proptosis  is  noted.  (Fig.  27.)  Discoloration  of  the 
upper  lid  is  more  frequent  than  in  the  lower.  Epistaxis 
occurs  often.  Edema  is  occasionally  noted  over  the 
thickened  part  of  the  limbs  and  about  the  face.  The 
visceral  mucous  membranes  are  commonly  the  seat  of 
hemorrhage,  resulting  in  hemorrhages  from  the  gastro- 
intestinal tract  and  the  genito-urinary  tract.  The  appear- 
ance of  blood  in  the  vomitus  and  feces  varies  with  its 
source  and  the  time  that  it  has  been  in  contact  with  the 
digestive  juices.  The  urine  is  usually  diminished  in 
volume,  may  contain  albumin,  casts,  red  and  white  blood 
cells  in  the  presence  of  hemorrhage.  An  early  appear- 
ance of  blood  stained  urine  is  not  uncommon.  Pus  cells 
may  be  present  in  considerable  numbers  after  the  sub- 
sidence of  the  hemorrhage.  Pyrexia  in  infantile  scurvy, 
although  rather  the  exception  than  the  rule,  is  by  no 
means  a  rarity.  The  temperature  may  be  raised  to  101° 
or  102°  F.  when  the  infant  comes  under  treatment,  but 
it  subsides  generally  within  a  few  days  as  the  acute 
symptoms  of  scurvy  disappear.  Hess  describes  the 
cardio-respiratory  syndrome,  consisting  of  increased 
pulse  and  heart  beat  often  over  150,  with  respirations 
reaching  50  to  60.  He  believes  that  these  phenomena 
may  be  associated  with  a  disturbance  of  the  vagus 
mechanism.  Further  changes  in  the  nervous  system  may 
be  present,  due  to  hemorrhage  or  focal  degeneration. 


SCURVY.  375 

The  paresthesias  due  to  peripheral  nerve  involvement 
have  been  described.  Increased  deep  reflexes  are  usually 
present.  The  diagnosis  of  the  subacute  type  is  not  al- 
ways possible  by  the  clinical  findings  and  may  be  de- 
pendent upon  the  reaction  to  antiscorbutic  diets.  The 
possibility  of  its  existence  should  always  be  considered 
in  the  presence  of  an  insufficient  or  improper  diet  and 
when  infants  are  fed  on  heated  milk,  which  is  over  long 
periods  without  the  addjtion  of  antiscorbutics  to  their 


Fig.  27. — Scurvy.     Bilateral  proptosis,  with  discoloration 
about  the  eyes  and  hemorrhages  into  the  conjunctive. 

diet.  Such  infants  usually  show  evidence  of  malnutri- 
tion and  anemia,  loss  of  appetite,  increased  tendon  re- 
flexes, irritability  and  rapid  pulse  and  respiration.  In 
this  class  of  cases,  unless  the  diet  is  corrected,  the  typi- 
cal clinical  picture  may  be  precipitated  at  any  time  if 
the  diagnosis  is  correct. 

Radiological  Diagnosis.  The  diagnosis  of  the  dis- 
ease in  advanced  cases  may  be  made  by  the  use  of  radio- 
grams. The  density  of  the  subepiphyseal  region  is  ma- 
terially diminished  where  the  lack  of  bone  formation  is 
especially  marked.  Just  above  this  area,  traversing  the 
shaft  in  its  transverse  diameter,  an  irregular  zone  of 


376  INFANT  FEEDING. 

increased  density  is  seen  in  advanced  cases  of  scurvy. 
This  is  seen  as  a  lighter  zone  in  the  radio  graphic  nega- 
tives and  is  described  as  the  "white  line  of  Fraenkel." 
This  shadow  can  especially  well  be  seen  on  the  lower 
end  of  the  femur  and  the  distal  ends  of  the  bones  of  the 
forearm.  This  shadow  receives  its  explanation  from 
the  anatomical  finding  in  this  portion  of  the  diaphysis 
of  an  irregular  chaos  of  calcined  trabeculse,  calcium  and 
bony  detritus,  and  also  of  bone  marrow  mixed  with 
masses  of  blood  and  pigment.  The  structure  of  the 
spongiosa,  which  normally  extends  down  to  the  place  of 
transition  of  the  shaft  into  the  epiphysis,  becomes  sud- 
denly broken  and  is  replaced  by  a  tissue,  thickened  by 
compression,  and  showing  no  more  an  orderly  structure 
of  trabeculae,  and  this  abnormal  tissue  shows  a  cor- 
responding shadow  appearing  always  in  the  same  posi- 
tion on  the  radiogram.  From  the  above  discussion  it 
becomes  clear  that  a  certain  degree  of  alterations  in  the 
bone  is  prerequisite  for  the  appearance  of  a  shadow  in 
the  radiogram.  This  is  known  as  the  "white  line  of 
Fraenkel."  (See  Figs.  24  and  25.)  If  this  degree  has  not 
been  reached,  then  the  shadow  is  absent,  even  though 
the  disease  be  present.  A  similar  shadow  is  not  infre- 
quently seen  in  severe  cases  of  rickets.  Less  constant 
than  this  shadow  are  the  subperiosteal  shadows  at  the 
seat  of  hemorrhages.  (See  Figs.  23  and  25.)  These 
shadows  may  be  invisible,  even  at  the  height  of  hemor- 
rhage, becoming  more  and  more  distinct  with  age,  due 
to  the  deposit  of  osteophytes.  Fractures  and  infractions 
are  demonstrable  in  scurvy.  Other  findings  in  scurvy 
are  epiphyseal  separation  and  displacements,  hemor- 
rhages within  the  joint  capsule  and  occasionally,  but 
rarely,  intramuscular  hemorrhages  may  be  demonstrated. 
Diagnosis.  In  the  differential  diagnosis  of  scurvy 
the  possibility  of  its  existence  and  itsjdiaracteristic  symp- 
toms must  constantly  be  borne  in  mind.  The  presence 
of  tenderness  over  the  bones  and  tendency  to  fixation 


SCURVY.  377 

of  the  joints,  the  usual  presence  of  multiple  joint  in- 
volvement, with  evidence  of  hemorrhage  in  other  parts 
of  the  body,  in  infants  usually  between  6  and  18  months 
of  age  and  the  history  of  improper  diet  or  prolonged 
lactation,  should  lead  to  the  suspicion  of  the  presence 
of  scurvy. 

Rachitis.  When  marked  rickets  is  present  the  recog- 
nition of  a  superimposed  scurvy  is  often  difficult  and  a 
careful  clinical  study  of  the  case  may  be  necessary  for 
its  recognition,  unless  the  complicating  symptoms  are 
pronounced.  The  dietetic  test  is  the  best  means  of  dif- 
ferentiation in  the  moderate  types. 

Rheumatic  Fever.  Pain,  tenderness  and  swelling  of 
the  limbs  in  infants  under  18  months  should  always  lead 
to  the  suggestion  of  scurvy.  In  rheumatic  fever  the 
tenderness  is  usually  associated  with  the  joints  and  local- 
ized, while  in  scurvy  there  is  almost  invariably  shaft 
involvement,  even  in  the  presence  of  joint  involvement. 
The  feeding  history,  presence  of  hemorrhages  into  the 
skin  and  from  the  mucous  membranes  will  often  com- 
plete the  diagnosis. 

Syphilis.  Syphilitic  osteochondritis  is  usually  asso- 
ciated with  a  history  of  early  lesions — most  commonly 
it  occurs  before  the  sixth  month  and  shows  the  charac- 
teristic blood  and  spinal  fluid  findings  in  the  infant  and 
parents.  The  painful  swellings  are  usually  seen  about 
the  ends  of  the  long  bones  and  the  radiological  findings 
are  characteristic.  In  later  manifestations,  in  which 
periostitis  ossificans  is  a  very  important  finding,  we  see 
newly  formed  subperiosteal  masses  with  bony  structure. 
They  are  usually  most  marked  in  the  middle  of  the  di- 
aphysis  of  the  tibia.  Old  cortex  may  often  be  differen- 
tiated from  the  newly  formed  subperiosteal  bony  masses. 
Cortical  thickening  is,  therefore,  an  important  point  in 
differential  diagnosis. 

Purpura.  This  disease  is  characterized  by  hemor- 
rhage, particularly  into  Jhe  skin.  It  is  very  rare  in  in- 


378  INFANT  FEEDING. 

fants.  It  can  usually  be  excluded  by  the  tenderness  of 
the  shafts  of  the  long  bones  in  scurvy.  The  roentgeno- 
logical  findings  of  scurvy  will  be  absent.  The  intestinal 
and  skin  hemorrhages  in  the  late  stages  of  athrepsia  may 
lead  to  some  confusion  unless  a  careful  history  is  taken. 

Osteomyelitis.  Scurvy  is  frequently  mistaken  for 
osteomyelitis  by  those  who  forget  the  possibility  of  the 
former.  Osteomyelitis  is  usually  confined  to  one  limb, 
is  characterized  by  a  continued  high  febrile  reaction, 
and  by  leucocytosis,  and  lacks  the  tendency  to  hemor- 
rhages in  other  parts  of  the  body.  The  diagnosis  can 
be  settled  by  X-ray  examination. 

Simple  Fractures  and  Dislocations.  These  can  usually 
be  differentiated  by  the  history  of  trauma,  the  singleness 
of  the  lesion  and  the  absence  of  other  typical  clinical 
and  radiographic  lesions. 

Tuberculous  Bone  and  Joint  Lesions.  The  radio- 
graphic  findings  are  usually  sufficient  for  the  differen- 
tiation of  these  two  conditions. 

Bone  Tumors.  The  malignant  types  are  characterized 
by  severe  systemic  reaction,  the  usual  finding  of  a  single 
bone  lesion  and  the  tendency  to  metastases  in  the  visceral 
organs. 

Poliomyelitis.  The  pseudo-paralysis  of  scurvy  may 
be  mistaken  for  this  condition.  In  the  differentiation 
the  history  of  an  acute  febrile  onset  in  an  infant  previ- 
ously in  good  health  and  the  tendency  to  general  tender- 
ness of  extremities,  rather  than  localized,  must  be  con- 
sidered. The  further  progress  of  the  case  will  usually 
complete  the  diagnosis. 

Acute  Nephritis.  In  the  presence  of  edema  and  the 
urine  containing  albumin,  casts  and  blood,  the  differen- 
tiation may  be  very  difficult  and  it  is  not  to  be  forgotten 
that  acute  nephritis  may  be  present  as  a  complication  of 
scurvy.  The  course  of  the  disease  and  the  reaction  to 
dietetic  treatment  may  be  the  only  means  of  differentia- 
tion, as  to  the  importance  of  the  urinary  findings. 


SCURVY.  379 

Pleuritic  and  Peritonitic  Pain.  A  careful  study  of 
the  chest  and  abdominal  viscera  for  evidence  of  acute 
inflammatory  conditions  are  necessary  to  eliminate  the 
possibility  of  a  confusion  in  the  diagnosis  between  in- 
flammatory changes  in  these  parts. 

All  other  conditions  associated  with  bone  and  blood 
changes,  and  in  the  latter  leading  to  hemorrhage,  may 
at  times  require  differentiation. 

Prognosis.  There  are  few  diseases  in  which  the 
effect  of  treatment  is  so  striking  as  in  mild  infantile 
scurvy;  under  efficient  antiscorbutic  diet  the  tenderness 
and  pain  on  movement  are  usually  appreciably  less  in 
forty-eight  hours;  although  such  rapid  diminution  of 
the  tenderness  and  pain  may  be  expected,  other  symp- 
toms persist  longer;  the  subperiosteal  hemorrhages,  if 
large,  may  cause  some  deep  thickening  to  remain  for 
two  or  three  weeks.  Occasionally  the  thickening  re- 
mains for  many  weeks  or  months,  in  spite  of  the  com- 
plete disappearance  of  all  other  symptoms  of  scurvy.  It 
should  be  remembered  that  an  individual  tendency  to 
scurvy  may  exist  and  that  further  indiscretions  in  diet 
may  readily  lead  to  recurrences.  In  severe  cases  the 
prognosis  must  be  guarded  because  of  the  liability  to 
severe  hemorrhages,  syncope  from  the  profound  ane- 
mia, and  death  from  diarrhea,  broncho-pneumonia  or 
exhaustion. 

Treatment.  Prophylaxis.  In  discussing  the  etiology, 
certain  facts  were  mentioned,  which  it  is  of  importance 
to  bear  in  mind  in  a  consideration  of  the  prophylactic 
treatment  of  scurvy,  namely :  that  this  disease  is  the 
result  of  the  deficiency  or  absence  of  a  certain  substance 
in  the  diet,  which  in  all  probability  belongs  to  the  so- 
called  group  of  vitamines.  Human  milk  usually  con- 
tains a  sufficient  amount  of  this  antiscorbutic  to  protect 
the  infant,  fresh,  raw  cow's  milk,  although  relatively  low 
in  it,  contains  enough  for  the  normal  development  of 
the  infant  if  given  in  sufficient  quantities,  although  its 


380  INFANT  FEEDING. 

content  varies  with  the  diet  of  the  cow.  This  anti- 
scorbutic is  reduced  or  destroyed  by  the  ageing  of  milk; 
heating  the  milk  has  the  same  influence.  Proprietary 
foods  and  cereals  are  especially  prone  to  be  deficient 
foods  because  of  the  process  of  heating  in  their  prepara- 
tion and  the  low  vitamine  content  of  the  cereals.  Many 
fruit  juices  and  certain  vegetables,  especially  if  fresh, 
are  rich  in  antiscorbutic.  With  this  knowledge  at  hand, 
scurvy  can  nearly  always  be  prevented  by  proper  atten- 
tion to  the  antiscorbutic  value  of  the  diet  in  infant  feed- 
ing. If  the  diet  is  low  in  antiscorbutic,  it  should  be  sup- 
plemented by  sufficient  quantities  of  foods  known  to  be 
rich  in  this  substance. 

If  babies  are  breast-fed,  they  rarely  develop  scorbutus, 
so  that  breast  feeding  is  one  of  the  best  preventive 
measures.  To  avoid  the  danger  of  the  vitamine  content 
of  the  milk  becoming  too  low,  the  lactating  mother 
should  partake  of  a  liberal  amount  of  cow's  milk,  leafy 
vegetables  and  fruits.  Moreover,  when  the  mother's 
milk  is  scanty  and  so  quantitatively  poor  in  antiscorbutic, 
sufficient  cow's  milk,  vegetables  and  orange  juice  should 
be  added  to  the  infant's  diet  to  fulfill  the  baby's  vita- 
mine  requirements.  In  the  artificially  fed,  sufficient 
quantities  of  fresh,  raw  cow's  milk  will  usually  prevent 
scurvy,  but  the  great  danger  of  bacterial  infection  from 
contaminated  raw  milk  usually  more  than  counter- 
balances the  danger  of  this  disease.  Consequently,  un- 
less certified  milk  can  be  obtained,  it  is  better  to  boil 
the  milk,  even  if  previously  commercially  pasteurized, 
and  during  the  very  hot  weather  we  even  advise  boiling 
certified  milk.  If,  however,  fresh  raw  milk  is  used,  too 
dilute  a  modification  should  not  be  given,  as  here  again 
the  quantitative  amount  of  antiscorbutic  may  be  insuf- 
ficient. This  milk  should  be  obtained,  if  possible,  from 
cows  properly  fed  on  plenty  of  greens.  During  the 
winter,  when  the  diet  of  the  cattle  is  mostly  grains,  even 
the  very  young  infants  should  be  given  orange  juice. 


SCURVY.  38! 

The  number  of  babies  fed  on  heated  milk,  either  pas- 
teurized or  boiled,  is  continually  increasing.  An  anti- 
scorbutic, such  as  orange  juice,  lemon  juice,  tomatoes, 
etc.,  should  in  every  instance  be  given  to  these  infants. 
We  start  as  early  as  the  sixth  week  with  five  drops 
diluted  with  water,  twice  daily,  and  gradually  increased 
until  two  to  four  drams  are  given  daily  by  the  third 
month  and  about  one  ounce  by  the  fifth  or  sixth  month, 
so  as  to  prevent  the  vitamine  deficiency  for  even  a  short 
period  and  thereby  avoid  the  danger  of  latent  scurvy. 
If  the  babies  object  to  it,  it  may  be  diluted  with  water 
and  a  little  cane  sugar  added.  If  it  is  regurgitated,  a 
small  amount  of  alkali  may  be  added  just  before  feed- 
ing and  then  it  is  usually  better  tolerated.  Orange  juice 
is  continued  throughout  early  childhood.  Strained, 
warmed  (not  cooked)  tomatoes,  either  raw  or  canned, 
may  be  used  instead  of  orange  juice,  in  doses  of  one 
dram  to  one  ounce  daily.  (The  latter  may  be  given  to 
infants  over  three  months  of  age.)  These  are  as  well 
borne  as  orange  juice,  even  by  very  young  infants.  Later 
on,  potatoes  cooked  with  their  jackets  on  serve  as  effici- 
ent antiscorbutics,  as  do  also  the  leafy  vegetables.  As 
cooked  vegetables  have  lost  considerable  of  their  anti- 
scorbutic potency,  the  amount  fed  must  be  sufficient  to 
protect  against  scurvy.  One  tablespoonful  a  day  is  usu- 
ally adequate.  The  vegetables  should  be  as  fresh  and 
young  as  possible. 

Proprietary  and  other  foods  subjected  to  prolonged 
heating  should  be  avoided  as  much  as  possible 
and  if  given  must  be  supplemented  by  sufficient  quan- 
tities of  antiscorbutics. 

The  basis  of  all  infants'  diets  should  be  fresh,  clean 
milk. 

Active  Therapy.  When  scurvy  develops,  the  active 
treatment  is  mainly  dietetic,  no  medicinal  agent  influenc- 
ing the  underlying  condition.  Orange  juice  must  be 
given  at  once,  starting  with  small  doses  of  a  few  drams 


382  INFANT  FEEDING. 

daily  and  rapidly  increasing  within  two  days  or  so  to 
one  or  two  ounces.  This  may  all  be  given  at  one  time, 
an  hour  before  the  mid-morning  feeding,  or  divided  into 
two  or  three  doses.  Exceptionally,  in  extremely  severe 
cases,  when  orange  juice  cannot  be  given  by  mouth,  it 
may  be  boiled,  filtered  and  rendered  faintly  alkaline,  and 
administered  intravenously.  Lemon  juice  is  just  as  ef- 
ficient but  less  palatable.  Orange  juice  will  cure  scurvy, 
even  if  the  causative  food  is  continued,  because  the  fruit 
juice  supplies  the  lacking  element  in  the  diet.  It  is  bet- 
ter to  change  the  food,  however,  unless  there  is  some 
special  indication  for  continuing  it.  Fresh  milk,  even 
if  boiled,  should  be  added  in  sufficient  quantities  if  the 
diet  contains  too  little  milk.  Fresh  green  vegetables  or 
vegetable  soup  may  be  added  to  the  diet  if  the  child  is 
old  enough  to  digest  them.  A  tablespoonful  daily  of 
boiled,  mashed  potato  is  a  good  antiscorbutic.  Other 
vegetables,  as  tomatoes,  carrots,  celery,  turnips,  and 
green  leaves,  are  good  antiscorbutics  but  their  efficacy 
is  much  below  orange  juice.  They  should  be  fed  when 
the  infant's  age  permits.  (See  additional  foods,  page  161.) 

Even  in  the  acute  florid  type  of  scurvy,  recovery  is 
rapid  and  complete  under  the  above  treatment.  Ten- 
derness of  the  extremities  disappears  in  a  few  days  and 
the  hematuria  usually  ceases  within  a  week.  The  swell- 
ing lasts  much  longer.  The  dietetic  treatment  should 
be  continued  .for  a  period  of  months  so  that  bones  and 
tissues  may  be  fully  restored  to  normal. 

Actively  scorbutic  infants  should  be  moved  and  han- 
dled as  little  as  possible  for  the  first  few  days  under 
treatment.  Sedatives  may  be  necessary  for  the  first  day 
or  so  to  control  the  pain.  If  fractures  or  epiphyseal 
dislocations  occur,  splints  are  necessary  for  immobiliza- 
tion. In  cases  of  marked  anemia  and  severe  hemor- 
rhages, a  blood  transfusion  may  help.  During  con- 
valescence, iron  preparations  should  be  given. 


SCURVY.  333 

Rachitis,  if  present,  should  be  recognized  and  treated 
simultaneously. 

Good  hygienic  surroundings  should  be  provided  to  aid 
in  convalescence. 


PART  VIII. 
Acidosis. 


BY  the  term  acidosis  we  refer  to  that  condition  in 
which  there  is  a  diminution  in  the  reserve  supply  of 
fixed  bases  in  the  body  fluids  and  tissues.  The  physio- 
chemical  reaction  of  the  blood  remains  unchanged  ex- 
cept in  extreme  conditions. 

Acidosis  may  result  from  any  one  of  the  following 
factors  or  a  combination  of  them : 

(1)  An  insufficient  intake  of   food  and  fluid,  with  re- 
sulting   dehydration,     or    excessive    production    of 
acetone    bodies,    or    both.       (Anorexia,    starvation, 
vomiting  and  diarrhea.) 

(2)  Incomplete  oxidation  of  the  organic  acid   radicals. 
(Diabetes,   cyclic   vomiting,   infections,   anhydremia, 
and   conditions   resulting  in   insufficient  aeration   of 
the  blood  as  cardiac  and  pulmonary  disease,  suffo- 
cation, excessive  exercise,  etc.) 

3)  Defective  neutralization  of  acid  in  the  body  by  am- 
monia. (Nephritis.)  This  is  due  to  the  fact  that 
the  acid  phosphates  causing  the  acidosis  fail  to  call 
forth  ammonia  production  rather  than  the  failure 
of  ammonia  production  per  se. 
(4)  Inadequate  elimination: 

a.  Of  carbon  dioxide  by  the  lungs.     (Pulmonary 

disease.) 

b.  Of  acid  by  the  kidneys.     (As  acid  phosphates 

in  nephritis  and  anhydremia.) 

A  sharp  distinction  must  be  drawn  between  aceto- 
nuria  and  acidosis.  This  is  necessary  because  of  the 
wide-spread  confusion  which  has  arisen,  in  the  interpre- 
tation of  the  relationship  which  acetonuria  bears  to  acid- 

(384) 


ACIDOSIS.  385 

osis.  Acetonuria  consists  merely  in  the  presence  of 
acetone-bodies  in  the  urine,  and  may  or  may  not  be 
accompanied  by  symptoms  of  acidosis.  Acetone  body 
acidosis  should  be  applied  to  that  condition  in  which  an 
excess  of  these  bodies  are  present  in  sufficient  quantity 
to  neutralize  enough  of  the  bases  to  appreciably  diminish 
the  alkali  reserve.  Acidosis  may,  however,  be  due  to 
an  excess  of  other  acid-bodies,  such  as  acid  phosphates, 
lactic  acid  and  carbonic  acid. 

Mechanism  of  Acid-base  Equilibrium.  As  the  blood 
plasma  has  approximately  the  same  composition  as  the 
tissue  juices  and  the  relative  alkalinity  of  the  tissues  has 
a  fairly  constant  relation  to  the  alkalinity  of  the  plasma, 
it  is  sufficient  to  study  the  regulation  of  the  acid-base 
equilibrium  in  the  blood.  Acids  are  constantly  being 
produced  in  the  course  of  metabolism.  Protection  is 
afforded  the  body  against  these  in  fundamentally  the 
same  manner  in  health  and  disease.  In  the  latter  the 
body  responds  within  its  reserve  capacity  by  a  quanti- 
tative increase  in  its  normal  processes  of  oxidation,  ex- 
cretion and  neutralization. 

The  blood  is  normally  slightly  alkaline.  Nevertheless, 
by  virtue  of  its  carbonates,  phosphates  and  proteins,  it 
can  neutralize  a  moderate  amount  of  acid.  This  ability 
to  neutralize  acid  or  base  is  termed  "titratable  value" 
in  distinction  from  the  actual  reaction.  The  true  or  ac- 
tual reaction  of  a  fluid  concerns  itself  only  with  that 
portion  of  acid  or  base  which,  after  going  into  solution, 
becomes  dissociated  into  hydrogen  and  hydroxyl  ions. 
The  titration  value  of  a  solution  is  a  broader  term,  since 
it  includes  not  only  the  free  hydrogen  and  hydroxyl  ions 
present,  but  all  the  reserve  of  undissolved  and  undis- 
sociated  hydrogen  or  hydroxyl,  which  can  be  liberated 
as  ions. — Sellards.1  Henderson2  has  pointed  out  and 


1  Sellards,  A.  W. :  Princ.  of  Infant  Feeding,  Harvard  U.  Press, 
'1917. 

2  Henderson,  L.  J. :  Amer.  Jour,  of  Physiology,  Vol.  21,  1908, 

p.  427.  os 


386  INFANT  FEEDING. 

established  that  the  mono-  and  di-  sodium  phosphates  and 
carbonates  of  the  blood  constitute  one  of  the  funda- 
mental features  in  the  regulation  of  neutrality,  since  the 
monosodium  salt  (NaH2PO4)  is  acid  and  the  disodium 
salt  (Na2HPO4)  is  alkaline.  The  normal  carbonate  and 
bicarbonate  of  the  serum  act  in  a  similar  manner  and  are 
present  in  much  larger  quantities  and  therefore  of  even 
greater  importance.  This  mixture  of  phosphates  and  car- 
bonates is  the  most  effective  in  maintaining  a  constant  re- 
action; it  is  extremely  efficient  not  only  in  aqueous  solu- 
tion but  in  the  presence  of  proteins,  such  as  serum  affords, 
and  these  moderately  enhance  its  value.  This  action  is 
practically  limited  to  the  hemoglobin,  the  other  blood  pro- 
teins having  very  little  action  in  retaining  the  constant  re- 
action of  the  blood,  on  account  of  the  fact  that  they  are 
inefficient  in  the  particular  reaction  of  the  blood  although 
on  other  reactions  they  have  a  marked  effect.1  Free  car- 
bonic acid  is  present  in  the  body  fluids  in  such  concentra- 
tion that  it  automatically  converts  into  bicarbonate  all 
bases  not  bound  by  other  acids.  The  bicarbonate,  there- 
fore, under  the  conditions  existing  represents  the  excess 
of  base  which  is  left  after  all  the  non-volatile  acids  have 
been  neutralized  and  is  available  for  the  immediate  neu- 
tralization of  further  acids.  In  this  sense  it  constitutes  the 
alkaline  reserve  of  the  body. — Van  Slyke.2  The  bicar- 
bonate concentration  of  the  blood  is  representative  of  that 
of  the  body  fluids  in  general,  and  is  normally  maintained 
at  a  definite  level,  which  forms  approximately  a  0.3  per 
cent,  solution  in  the  blood  plasma.  Entrance  of  free  acids 
reduces  it  to  an  extent  proportional  to  the  amount  of 
the  invading  acid.  Sodium  bicarbonate  is  the  chief  sub- 
stance concerned  with  this  mechanism.3  The  proteins 
and  phosphates  in  the  blood  play  a  lesser  role.  An  acid 
or  even  a  neutral  reaction  of  the  blood  is  incompatible 


1  Henderson,  Y. :  Jour.  Biol.  Chem.,  1920. 

2  Van  Slyke,  D.  D. :  Jour.  Biol.  Chem.,  1917,  Vol.  30,  p.  289. 

3  Rowland  and  Marriott :  Penna.  Med.  Jour.,  Vol.  21,  1918,  p. 
429. 


ACIDOSIS.  387 

with  life,  so  that  the  phrase  "increased  acidity"  really 
means  reduced  alkalinity. 

Carbonic,  phosphoric,  sulphuric  and  among  the  organic 
lactic  acids  are  normally  formed  as  end  products  in  the 
metabolic  processes.  These  acid  substances  must  be  neu- 
tralized and  excreted  without  disturbing  the  normal  de- 
gree of  alkalinity  of  the  tissues  if  the  organism  is  to 
remain  in  a  state  of  health.  When  there  is  an  inability 
on  the  part  of  the  body  to  maintain  its  alkali  reserve, 
acidosis  results. 

The  defenses  of  the  body  against  acidosis  are  princi- 
pally pulmonary  ventilation,  excretion  of  acids  by  the 
renal  tissues  and  neutralization  of  acids  by  ammonia. 

Pulmonary  Ventilation.  In  the  blood  carbonic  acid 
in  part  unites  with  the  alkalies  in  the  blood  to  form  bi- 
carbonate and  some  remains  in  the  solution  in  the  plasma. 
The  venous  blood  thus  loaded  with  carbonic  acid  is  car- 
ried to  the  capillaries  of  the  lung  tissue.  Here  carbon 
dioxide  diffuses  through  the  thin  capillary  and  alveolar 
walls  into  the  alveolar  air  because  the  pressure  of  CC>2 
is  less  in  the  inspired  air  than  in  the  blood.  Thus,  car- 
bon dioxide  is  given  off  by  the  lungs  without  the  loss 
of  alkalies  from  the  body  and  the  blood  becomes  more 
alkaline  again.  If  an  excess  of  carbonic  acid  accumu- 
lates in  the  blood,  even  a  very  small  increase  of  the 
H  ion  concentration  stimulates  the  respiratory  center, 
with  a  resulting  increased  rapidity  and  depth  of  respira- 
tion and  increased  CO2  excretion.  Sellards  has  a  some- 
what different  explanation  for  this  hyperpnea.  He  main- 
tains that  as  the  fixed  bases  become  depleted  the  oxygen 
is  still  carried  by  the  arterial  blood  but  the  resulting 
carbon  dioxide  gradually  accumulates  in  the  tissues, 
since  there  is  not  an  adequate  supply  of  bases  for  trans- 
porting it  to  the  lungs.  With  this  accumulation  of  car- 
bon dioxide,  the  tissues  are  no  longer  able  to  utilize  the 
oxygen  brought  to  them;  the  individual  becomes  dys- 
pneic  and  suffers  from  subjective  symptoms  of  suffo- 


388  INFANT  FEEDING. 

cation  just  as  though  he  were  deprived  of  air.  The 
oxygen,  since  it  cannot  be  taken  up  by  the  tissues,  re- 
mains in  the  venous  blood,  giving  it  an  arterial  color. 

Rowland  and  Marriott1  state:  If,  on  the  other  hand, 
an  acid,  such  as  beta-oxybutyric  or  lactic,  is  poured  into 
the  plasma,  as  it  passes  through  the  tissues,  a  certain 
amount  of  the  bicarbonate  is  neutralized  and  carbon  di- 
oxide is  set  free  in  solution.  The  excess  of  carbon  di- 
oxide is  removed  as  before  and  the  blood  reaction  returns 
to  normal.  Some  bicarbonate  has,  however,  been  neu- 
tralized so  that  the  plasma  has  become  a  weaker  solution 
of  bicarbonate.  When  this  solution  takes  up  carbon 
dioxide  from  the  tissues  its  reaction  becomes  more  acid 
with  the  same  amount  of  dissolved  carbon  dioxide  as 
formerly.  Roughly  speaking,  if  the  bicarbonate  of  the 
plasma  is  reduced  one-half,  only  half  as  much  carbonic 
acid  can  be  carried  in  solution  as  formerly,  if  the  re- 
action is  to  remain  the  same  as  before.  By  doubling 
the  ventilation  in  the  pulmonary  alveoli  the  dissolved 
carbonic  acid  of  the  plasma  may  be  diminished  about 
one-half;  at  the  same  time  the  concentration  or  tension 
of  carbon  dioxide  in  the  pulmonary  alveoli  is  also  dimin- 
ished one-half.  The  carbon  dioxide  tension  in  the  al- 
veolar air,  for  this  reason,  is  a  measure  of  the  extent 
to  which  the  bicarbonate  reserve  of  the  plasma  is  de- 
pleted, and  increased  pulmonary  ventilation  is  one  of  the 
symptoms  of  acidosis. 

Increased  pulmonary  ventilation  serves  to  prevent  a 
significant  change  in  the  reaction  of  the  blood,  but  it 
cannot  prevent  a  depletion  of  the  bicarbonate  reserve 
of  the  plasma.  This  reserve  eventually  would  be  en- 
tirely exhausted  were  it  not  for  other  means  of  defense 
and  for  the  provision  for  a  replenishment  of  the  alkali 
reserve. 

Excretion  of  Acid  by  Renal  Tissues.  An  acid  urine 
is  excreted  normally  by  the  kidneys  from  an  alkaline 


1  Rowland  and  Marriott :  Ibid. 


ACIDOSIS.  389 

blood,  thus  sparing  alkalies  to  neutralize  more  acids  of 
metabolism.  A  small  amount  of  free  acid  is  present  in 
the  urine.  Most  of  the  acid  in  the  urine,  however,  is 
excreted  as  acid  phosphate  which  is  formed  from  the 
alkali  phosphate  of  the  blood  plasma,  by  the  follow- 
ing reaction:  Na2HPO4  plus  H2O  plus  CO2,  equals 
NaH2PO4  (excreted  in  urine)  plus  HNaCO3  (remains 
in  the  blood).  The  base  thus  spared  serves  to  replenish 
the  bicarbonate  reserve.  Some  alkaline  phosphate  is, 
however,  excreted  in  the  urine,  and  although  no  alkali 
is  lost  through  the  lungs,  some  is  lost  in  the  urine  by  the 
excretion  of  the  salts  of  phosphoric,  sulphuric,  lactic  acid, 
etc.  To  compensate  for  this  alkali  loss  there  is  usually 
a  sufficient  quantity  of  alkalies  taken  with  the  food. 

Neutralization  of  Acids  by  Ammonia.  Ammonia 
formed  instead  of  neutral  urea,  neutralizes  acids  in  the 
plasma  and  is  excreted  in  the  urine  as  ammonium  salts. 
Ammonia  occurs  in  the  urine  physiologically  only  to  the 
extent  which  is  needed  for  the  neutralization  of  acids, 
the  remainder  of  the  ammonia  being  promptly  converted 
into  urea.  When  there  is  an  increased  accumulation  of 
acids  in  the  blood,  more  ammonia  is  formed  to  neutral- 
ize them  and  is  an  important  safety  factor  in  maintaining 
the  alkali  reserve.  The  presence  of  an  increased  amount 
of  ammonia  in  the  urine  does  not,  in  itself,  indicate  an 
acidosis  but  rather  that  the  body  is  reacting  to  prevent 
acidosis. 

Clinical  Types.  As  previously  stated,  it  is  necessary 
to  draw  a  distinct  line  between  acetonuria  and  acidosis. 
Most  of  the  studies  of  the  past  have  dealt  mainly  with 
the  acetone  body  acidosis.  However,  in  the  light  of 
more  recent  experimental  and  clinical  investigations  the 
prominence  of  other  acid  bodies  such  as  the  acid  phos- 
phates, carbonic  and  lactic  acid  have  assumed  a  more 
prominent  position  as  causative  factors,  either  as  distinct 
or  mixed  types  of  acidosis. 


390  INFANT  FEEDING. 

Acetone  Body  Acidosis.  Acidosis  in  the  course  of 
diabetes  is  a  recognized  representative  of  this  type.  The 
development  of  hyperpnea  and  drowsiness,  in  the  course 
of  diabetes,  indicates  clinically  that  such  an  acidosis  ex- 
ists. A  study  of  the  CO  2  tension  in  the  alveolar  air 
and  the  bicarbonate  reserve  of  the  plasma  should  always 
be  made  with  the  first  clinical  or  laboratory  evidence  of 
a  beginning  acidosis.  As  a  prophylactic  measure  such 
tests  should  be  made  at  regular  intervals  during  the 
course  of  the  disease.  Fortunately,  diabetes  is  a  rare 
disease  in  children,  but  a  very  fatal  one.  Acidosis  of 
this  type  occurs  in  the  presence  of  ileo-colitis  (bacillary 
dysentery),  also  at  times  at  the  onset  of  measles,  scarlet 
fever,  and  in  the  presence  of  respiratory  infections. 
Other  conditions,  such  as  recurrent  vomiting,  acute  in- 
fections and  nutritional  disturbances  which  are  com- 
monly associated  with  acetone  body  acidosis  will  be 
treated  individually  because  of  their  clinical  importance. 

Acidosis  in  the  Course  of  Acute  Infectious  Diseases. 
Acute  toxic  conditions  out  of  proportion  to  the  seeming 
severity  of  the  infection  are  frequently  seen  in  the  course 
of  acute  infectious  diseases  in  young  children.  They 
are  frequently  due  to  the  production  of  sufficient  amounts 
of  acid  bodies  to  cause  a  definite  acidosis.  This  increase 
in  acid  body  production  must  be  viewed  in  the  light  of 
an  expression  of  the  toxemia  and  not  as  the  cause  of  the 
condition.  The  clinical  picture  may,  however,  be  greatly 
influenced  by  the  production  of  these  substances. 

Acute  Upper  Respiratory  Tract  Infection  Associated 
with  Acidosis.  For  several  years  past  we  have  been 
experiencing  epidemics  of  acute  upper  respiratory  infec- 
tion associated  with  evident  inflammation  of  the  tonsils, 
pharynx,  naso-pharynx  and  nasal  mucous  membranes 
resulting  in  an  injection  and  glazed  appearance  of  the 
mucous  membranes.  It  is  frequently  unaccompanied  by 
follicular  involvement  of  the  tonsils.  Nausea  and  vomit- 
ing are  early  manifestations  and  may  disappear  in  one 


ACIDOSIS.  391 

or  two  days  or  in  fatal  cases  persist  throughout  the 
course  of  the  disease.  Usually  by  the  second  day  after 
the  beginning  of  vomiting  an  acetone  odor  is  noted  in 
the  breath.  Many  of  the  cases  early  show  acetone 
and  a  considerable  number  diacetic  acid  in  the  urine. 
Not  infrequently,  however,  the  mild  cases  run  their 
course  without  these  latter  findings.  Diarrhea  is  pres- 
ent in  some  of  the  cases  and  may  be  accompanied  by 
marked  evidence  of  intestinal  fermentation.  The  ma- 
jority of  our  cases,  however,  were  associated  with  a 
flat  abdomen  and  constipation.  In  the  severe  cases  hy- 
perpnea  develops  and  may  be  the  most  marked  of  all 
of  the  symptoms.  The  children  develop  anhydremia, 
features  are  drawn,  eyes  sunken,  skin  becomes  dry  and 
loses  its  turgor,  they  become  apathetic  and  later  stupor- 
ous,  and  unless  relieved  develop  profound  coma.  The 
epidemics  were  usually  seen  during  the  winter  and 
spring  months,  and  more  commonly  affect  children  be- 
tween the  ages  of  1  and  6  years.  Younger  infants,  how- 
ever, «nay  develop  this  condition  and  it  is  not  infrequently 
seen  in  the  breast-fed.  Physical  examination  in  the 
absence  of  tympany  usually  reveals  more  or  less  rigidity 
of  the  abdominal  muscles  and  an  enlarged  liver.  In 
some  of  the  severe  types  icterus  may  develop.  Throat 
cultures,  taken  early  in  the  course  of  the  disease,  have 
in  most  instances  in  my  cases  shown  a  short  chain  small 
streptococcus. 

What  relationship  the  acute  infection  in  the  pharynx 
bears  to  the  clinical  picture  is  undecided.  In  all  prob- 
ability it  is  due  to  a  general  toxemia.  However,  the 
possibility  of  an  acute  gastritis,  with  secondary  starva- 
tion, due  to  the  inability  to  retain  food,  must  not  be  over- 
looked as  the  possible  cause  of  the  acidosis. 

A  number  of  our  cases  were  seen  in  children  who 
had  previously  had  a  radical  tonsil  operation  performed, 
so  that  they  could  not  be  related  to  pus  infections  of 


392  INFANT  FEEDING. 

the  tonsils  themselves.  Rachford,1  who  has  described 
these  cases  under  the  title  of  "Epidemic  Acid  Intoxi- 
cation," has  seen  a  large  number  of  fatal  cases.  This 
has  not  been  our  experience  in  the  Chicago  epidemics, 
most  of  the  cases  running  a  comparatively  short  course 
of  from  two  tP  six  days,  ending  in  a  rapid  convalescence. 

Pulmonary  and  Cardiac  Diseases.  In  the  pneumonias, 
empyema  and  bronchial  asthma  and  other  types  of  mas- 
sive involvement  of  the  pulmonary  tissues,  and  in  car- 
diac diseases  associated  with  decompensation,  carbon  di- 
oxide frequently  accumulates  in  the  blood  in  amounts 
in  excess  of  the  normal,  resulting  in  a  carbon  dioxide 
acidosis.  This  leads  to  increased  stimulation  of  the  res- 
piratory center,  with  resulting  hyperpnea.  The  carbon 
dioxide  tension  in  the  alveolar  air  is  diminished  but  on 
account  of  the  peculiar  character  of  the  acid  causing  the 
acidosis  there  is  no  diminution  in  the  alkali  reserve.  In 
some  cases  Rowland  and  Marriott  found  that  lactic  acid 
was  produced  as  a  result  of  the  partial  asphyxia  and 
in  these  cases  a  slight  diminution  in  the  alkali  reserve 
was  noted. 

Chronic  Upper  Respiratory  Infections.  Sedgwick^ 
directs  attention  to  the  surprising  results  obtained  fol- 
lowing removal  of  the  tonsils  and  adenoids  in  some  of 
his  cases  of  recurrent  or  periodical  vomiting.  He  found 
that  not  infrequently  tonsillitis  or  rhino-pharyngitis  pre- 
ceded the  attacks.  The  possibility  of  focal  infection 
should  therefore  be  borne  in  mind  in  the  recurrent  types 
of  vomiting  associated  with  acidosis.  The  type  of  re- 
current vomiting,  probably  a  toxic  neurosis  which  re- 
sembles migraine  of  later  life  in  many  of  its  clinical  and 
laboratory  findings  and  familial  tendencies,  should  be 
given  due  consideration  in  an  analysis  of  this  group. 

Acidosis  Associated  With  Diarrhea!  Conditions.  It 
has  been  shown  by  Rowland  and  Marriott,3  and  the 

1  Rachford,  B.  K. :  Arch.  Fed.  vol.  37,  Nov.,  1920,  p.  651. 

2  Sedgwick,  J. :  Jour.  Dis.  of  Children,  iii,  1912,  209. 

3  Howland  and  Marriott :  Penna.  Med.  Jour.,  April,  1918. 


ACIDOSIS.  393 

work  has  been  confirmed  by  Yllpo1  and  Schloss,2  that, 
in  the  diarrhea  of  infants  accompanied  by  profuse  watery 
stools  (intoxication,  cholera  infantum,  anhydremia,  etc.), 
a  severe  acidosis  may  result.  It  is  not  present  in  all 
cases  of  diarrhea  but  may  be  a  very  serious  and  often 
a  fatal  complication.  The  carbon  dioxide  tension  of 
alveolar  air  is  low ;  frequently  it  sinks  to  20  mm.  or 
less,  the  alkali  tolerance  is  much  increased,  the  alkali 
reserve  is  greatly  diminished  and  the  hemoglobin  dis- 
sociation curve  is  altered.  Children  suffering  from  this 
form  of  acidosis  show,  in  addition  to  the  other  symp- 
toms referable  to  diarrhea  and  anhydremia,  hyperpnea 
and  psychic  changes. 

The  cause  of  this  acidosis  is  not  always  evident,  al- 
though it  is  in  all  probability  frequently  influenced  by 
an  insufficient  intake  of  food,  starvation  due  to  vomiting, 
anhydremia  through  loss  of  fluids  by  vomiting  and  diar- 
rhea, and  excessive  loss  of  bases  through  the  intestines 
and  disturbances  in  carbohydrate  metabolism  may  all  be 
factors.  Although  the  acetone  bodies  are  at  times  in- 
creased, they  may  be  within  normal  limits.  In  a  con- 
siderable number  of  cases  the  inorganic  phosphorus  of 
the  serum  is  increased.  The  anhydremia  results  in  a 
diminished  blood  volume,  with  a  secondary  diminished 
blood  flow  especially  in  the  capillaries,  which  leads  to  a 
partial  tissue  asphyxia  and  increased  lactic  acid  produc- 
tion.— Marriott. 

From  our  present  knowledge  we  are  led  to  believe 
that  increased  production  and  an  insufficient  elimination 
of  acids  is,  therefore,  largely  responsible  for  the  develop- 
ment of  acidosis  in  the  course  of  the  diarrheal  conditions. 

Acidosis  Secondary  to  Starvation.  It  is  a  well-known 
fact  that  in  partial  starvation  acetonuria  is  a  frequent 
finding.  The  same  is  true  when  patients  suffering  from 
infections  are  underfed.  The  presence  of  acetone  in 


1  Yllpo :  Ztschr.  f.  Kinderh.,  Vol.  xiv,  1916. 

2  Schloss,  O. :  Amer.  Jour.  Dis.  of  Children,  Vol.  13,  1917,  p. 


394  INFANT  FEEDING. 

these  cases  does  not  signify  that  they  must  necessarily 
be  in  a  state  of  acidosis. 

The  work  of  Yllpo,1  in  1914,  was  a  stimulus  to  the 
study  of  this  subject  in  new-borns.  He  claims  to  have 
found  that  the  human  organism  at  birth,  is  in  a  state 
of  "physiologic  acidosis;"  as  evidenced  by  chemical  ex- 
amination of  the  blood.  Sehan2  studied  ten  new-borns, 
from  1  hour  to  8  days  of  age,  and  found  that  during  the 
first  few  days,  when  the  baby  received  practically  no  food 
at  all,  there  was  no  definite  decrease  in  CO2  tension, 
which  is  indicative  of  acidosis  such  as  Yllpo  claims  to 
have  found.  His  results  with  the  alkali  tolerance  tests 
in  the  normal  new-borns  led  him  to  believe  that  they 
were  not  suffering  from  acidosis.  He  also  found  that 
acetone  is  practically  absent  from  the  urine  of  a  nor- 
mal new-born. 

Veeder,3  as  a  part  of  a  general  study  of  acetone  body 
acidosis  in  childhood,  made  a  number  of  experiments  to 
obtain  figures  of  the  degree  of  acetonuria  resulting  from 
inanition.  He  believes  that  there  is  but  little  increased 
output  of  acetone  bodies  during  a  period  of  twenty-four 
hours  inanition  in  a  healthy  child.  In  the  cases  in  which 
inanition  was  terminated  at  the  end  of  twenty-four  hours, 
there  was  a  continued  increased  elimination  of  acetone 
on  the  following  day,  which  in  some  instances  was  greater 
than  the  amount  eliminated  on  the  day  of  the  inanition. 
This  fell  rapidly,  so  that  by  the  second  day  normal  figures 
were  again  obtained. 

In  the  remaining  cases  the  inanition  period  was  con- 
tinued for  a  second  twenty-four  hours  before  the  child 
was  placed  on  the  original  diet.  A  rapid  increase  in 
acetone  elimination  took  place  during  the  second  twenty- 
four  hours. 


1  Yllpo,  A. :  Neugeborenen-Hunger  und  Intoxikationsacidosis,  J. 
Springer,  Berlin,  1916. 

2  Sehan,  M. :  Am.  Jour.  Dis.  of  Children,  Vol.  18,  1919,  p.  42. 

3  Veeder,  B. ;  Johnson,  M.  R. :  Am.  Jour.  Dis.  of  Children,  V. 
13,  1917,  p.  89. 


ACIDOSIS.  395 

Veeder  does  not  believe  that  there  is  a  relationship 
between  the  degree  of  acetonuria  and  the  state  of  the 
child's  nutrition,  thin  children  giving  the  same  results 
as  fat  ones.  He  found  that  the  amount  of  beta-hydroxy- 
butyric  acid  (in  terms  of  acetone)  eliminated  was  as  a 
rule  from  two  to  four  times  as  much  as  the  quantity  of 
combined  acetone  and  diacetic  acid. 

The  nitrogen  and  ammonia  of  the  urine  was  deter- 
mined daily.  There  was  at  most  a  very  slight  actual 
increase,  or  percentage  increase,  in  the  ammonia  elimina- 
tion on  the  first  day  of  inanition,  however,  later  a  marked 
increase  took  place. 

Gamble  and  his  co-workers,1  using  as  subjects  epileptic 
children  who  were  being  fasted  as  a  therapeutic  measure, 
undertook  to  determine  the  extent  to  which  the  reduction 
of  the  plasma  bicarbonate  during  fasting  is  due  (1)  to 
depletion  of  the  inorganic  base  of  the  plasma,  and  (2) 
to  the  concentration  of  ketone  acids  developing  in  the 
plasma.  It  was  found  that  the  total  inorganic  base  con- 
centration was  during  fasting  accurately  sustained  at  its 
usual  average  value.  The  reduction  of  bicarbonate  was 
thus  apparently  due  entirely  to  the  concentration  of  ab- 
normal organic  acids  in  the  plasma.  This  inference  was 
sustained  by  direct  measurements  of  the  concentration  of 
ketone  acids  in  the  plasma.  It  was  also  found  that  small 
amounts  of  sucrose  by  mouth  brought  about  a  restoration 
of  the  bicarbonate  concentration  to  its  usual  size.  From 
these  data  it  is  inferred  that  glucose  rather  than  bicar- 
bonate is  the  logical  agent  in  the  treatment  in  non-diabetic 
ketosis. 

Abt2  has  described  a  series  of  cases  of  acid  intoxi- 
cation recurring  in  infants  previously  healthy,  at  about 
the  weaning  period.  In  one  family  two  children  had 
previously  died  from  this  affection,  the  case  described 


1  Gamble,  J.  L.,  Ross,  S.  G.,  and  Tisdall,  F.  F. :  Transactions 
Amer.  Fed.  Society,  1922. 

2  Abt :  Amer.  J.  Med.  Sc.,  147,  1914,  86. 


396  INFANT  FEEDING. 

being  the  third  infant  born  to  this  family.  W.  F.  Orr 
had  reported  a  series  of  five  children  in  the  same  family 
who  died  with  symptoms  similar  to  those  described  by 
Abt.  The  illness  usually  occurs  in  large,  robust,  previ- 
ously healthy  infants — in  some  cases  the  infants  had 
shown  a  stationary  weight  curve  before  the  onset.  As 
in  some  of  his  cases  I  have  seen  three  cases  occurring 
in  infants  who  suddenly  weaned  themselves  because  of 
dissatisfaction  with  the  food  from  the  breast,  following 
which  they  also  declined  to  take  sufficient  artificial  food. 
As  several  of  our  cases  have  occurred  before  the  close 
of  the  period  of  lactation  the  question  arises  as  to 
whether  the  insufficient  breast  milk  supply  may  not  have 
led  to  partial  inanition  which  became  acute  with  spon- 
taneous refusal  of  artificial  food,  resulting  in  complete 
starvation.  The  possibility  of  infection  as  a  precipitat- 
ing factor  must,  however,  not  be  overlooked. 

Post-Operative  Acidosis.  Morriss1  found  that  the 
capacity  of  the  plasma  for  combining  with  the  carbon 
dioxide  is  decreased  after  ether  and  chloroform  anes- 
thesia; in  other  words,  one  influence  of  the  anesthetic 
is  toward  depletion  of  the  alkali  reserve. 

Jeans2  found  that  the  acetone  bodies  of  the  blood 
were  somewhat  increased  after  operation  in  about  two- 
thirds  of  the  children  studied,  the  maximum  amount  be- 
ing found  in  most  instances  about  twenty-four  hours  after 
operation.  The  plasma  carbonate  was  reduced  in  about 
two-thirds  of  the  cases,  the  greatest  reduction  occurring 
in  most  instances  about  twenty-four  hours  after  opera- 
tion. When  more  closely  compared  there  was  found  to 
be  no  close  relation  between  the  increase  of  acetone 
bodies  and  the  reduction  of  plasma  carbonate.  In  most 
instances,  especially  in  those  cases  in  which  the  plasma 
carbonate  was  much  reduced,  the  acetone  bodies  were 
entirely  inadequate  to  account  for  the  degree  of  reduc- 


1  Morriss :  Jour.  A.  M.  A.,  May  12,  1917. 

2  Jeans :  Papers  of  the  St.  Louis  Clinic,  1917. 


ACIDOSIS.  397 

tion  of  plasma  carbonate.  The  undetermined  acid  fac- 
tor was  apparently  of  much  greater  importance  than  the 
acetone  bodies  in  the  reduction  of  reserve  alkali.  The 
starvation  incident  to  operation  seems  to  play  no  part 
in  the  production  of  this  undetermined  factor. 

Acidosis  of  Renal  Origin.  .The  ability  of  the  kidneys 
to  excrete  acid,  especially  acid  phosphate,  is  one  of  the 
chief  defensive  mechanisms  of  the  body.  Failure  of 
this  mechanism  even  without  increased  production  of 
acids,  results  in  acidosis.  Occasionally  in  nephritis  acid- 
osis  occurs  and  Rowland  and  Marriott1  have  shown  that 
when  acidosis  is  present  there  is  an  accumulation  of  un- 
excreted  phosphate  in  the  blood  plasma.  There  is  no  evi- 
dence that  any  abnormal  acid  is  produced.  In  these  cases 
of  acidosis  where  hyperpnea  is  present,  the  CQz  tension  in 
the  alveolar  air  is  lower  than  normal,  the  alkali  reserve 
of  the  blood  is  depleted,  and  there  is  an  increased  "al- 
kali tolerance."  No  acetone  bodies  are  to  be  detected 
in  the  urine  and  the  ammonia  excretion  is  normal  or 
diminished.  Failure  to  produce  ammonia  to  neutralize 
the  retained  acid  is  an  additional  factor  in  the  produc- 
tion of  the  acidosis  of  nephritis,  and  represents  a  weak- 
ening of  another  of  the  body's  defenses. 

Acidosis  Secondary  to  Burns.  Acidosis  frequently 
develops  following  severe  burns.  Marriott  has  found 
this  to  be  a,  mixed  type  and  is  due  in  part  to  acetone 
bodies  and  in  part  to  lactic  acid. 

Symptoms.  The  onset  is  usually  relatively  insidious. 
An  early  and  the  most  important  sign  is  hyperpnea,  char- 
acterized by  deep,  pauseless  respirations.  The  rate  is 
usually  moderately  increased  as  compared  to  the  great 
increase  in  depth.  It  is  both  thoracic  and  abdominal, 
the  great  amplitude  of  the  respiratory  excursion  causing 
considerable  effort  and  often  the  accessory  respiratory 
muscles  are  brought  into  action.  This  type  of  breathing 


1  Rowland    and    Marriott :  Arch.    Int.    Med.,   Vol.    xviii,    1916, 
p.  708. 


398  INFANT  FEEDING. 

is  described  as  "air  hunger"  and  is  the  manifestation  of 
an  effort  to  increase  pulmonary  ventilation.  Eventually, 
in  fatal  cases,  there  is  exhaustion  of  the  respiratory  cen- 
ter, the  respirations  become  feebler  with  occasional  deep 
gasps  and  finally  cease.  Because  of  the  increased  aera- 
tion of  the  blood,  the  lips  and  cheeks  are  often  a  bright, 
cherry  red. 

The  sensorium  is  markedly  affected.  At  first,  there 
is  extreme  restlessness  and  excitement,  later  apathy, 
drowsiness  and  stupor  develops.  Anhydremia  frequently 
develops,  manifested  by  sunken  eyes,  depressed  fontanel 
and  dry  skin  hanging  in  folds,  more  especially  in  the 
presence  of  repeated  vomiting.  The  face  is  anxious  and 
pinched.  Diarrhea  may  accompany  the  acidosis.  A 
"fruity"  odor  of  the  breath  is  sometimes  present — this 
is  characteristic  of  acetone  body  acidosis  only.  Dex- 
trose alone,  or  in  combination  with  lactose  and  galactose, 
may  appear  in  the  urine,1  in  the  particular  form  of  acid- 
osis occurring  in  anhydremia.  The  degree  of  leucocy- 
tosis  and  fever  depends  upon  the  accompanying  disease. 
Hyperpnea  without  cyanosis  is  the  only  reliable  and 
pathognomonic  clinical  symptom.  The  various  laboratory 
tests  show  an  impending  acidosis  before  any  symptoms 
are  manifest.  The  laboratory  tests  confirm  the  diag- 
nosis. They  give  positive  evidence  of  the  presence  or 
absence  of  acidosis,  even  in  absence  of  characteristic 
symptoms. 

The  determination  of  the  carbon  dioxide  tension  in 
the  alveolar  air  is  a  relatively  simple,  bedside  procedure, 
if  the  colorimetric  method  of  Marriott2  is  used.  In 
infancy  the  normal  carbon  dioxide  alveolar  air  tension 
varies  from  37  to  45  mm.  Tensions  between  30  and 
35  mm.  indicate  a  mild  degree  of  acidosis,  below  30  mm. 


1  Schloss,  O. :  Amer.  Jour.  Dis.  of  Children,  xiii,  218,  1917. 

2  Marriott :  Jour.  A.  M.  A.,  Ixvi.  1594,  May  20,  1916.    Rowland 
and  Marriott :  Am.  Jour.  Dis.  of  Children,  xi,  309,  1916. 


ACIDOSIS.  399 

a  moderate,  and  below  25,  a  severe  acidosis,  and  below 
20  mm.  an  extreme  acidosis.1 

More  difficult,  but  more  accurate  are  the  determina- 
tions of  the  bicarbonate  content  of  the  plasma  by  the 
Van  Slyke  method.2  The  amount  of  CO2  given  off  is 
measured  after  strong  acids  are  added  to  a  certain  vol- 
ume of  blood  to  liberate  the  CO2.  In  infants  the  plasma 
contains  50  to  70  volumes  per  cent,  of  combined  CO2. 
Adults  have  about  10  per  cent.  more.  In  infants  amounts 
less  than  45  indicate  acidosis.  The  results,  if  multiplied 
by  0.7,  approximate  alveolar  carbon  dioxide  tension  in 
millimeters  determined  according  to  the  method  of  Mar- 
riott. As  mentioned  previously,  the  excessive  H  ions 
stimulate  respiration  and  the  excessive  acids  in  the  blood 
decompose  the  carbonates  so  that  CO2  is  blown  off 
through  the  lungs,  lowering  the  amount  combined  in  the 
blood.  Consequently,  this  test  indirectly  measures  the 
available  alkali  reserve  of  the  blood. 

Sellard's3  test  is  to  determine  the  alkali  tolerance  of 
the  individual.  Under  normal  circumstances,  the  inges- 
tion  of  small  quantities  of  sodium  bicarbonate  by  mouth 
increases  the  amount  of  this  substance  in  the  blood  and 
the  excess  is  rapidly  excreted  in  the  urine,  causing  the 
reaction  of  the  urine  to  become  amphoteric  or  alkaline 
to  litmus  temporarily.  Marriott  recommends  the  use  of 
brom-cresol  purple  in  2  per  cent,  alcohol  solution;  a 
drop  or  two  of  this  solution  is  added  to  a  small  amount 
of  urine  in  a  test  tube.  This  indicator  changes  from 
yellow  to  purple  at  about  the  normal  reaction  of  the 
urine  (PH6).  When  the  urine  turns  this  indicator  pur- 
ple, it  indicates  that  acidosis  is  not  present,  or  that  the 
acidosis  has  been  corrected.  If  the  indicator  does  not 
turn  purple,  it  may  or  may  not  mean  the  presence  of 
acidosis.  This  is  a  simple  test  which  can  easily  be  com- 


1  Rowland  and  Marriott :  Bull.  Johns  Hopkins  Hosp.,  xxvii,  63, 
1916. 

-  Van  Slyke,  D.  D. :  Jour.  Biol.  Chem.  xxx,  p.  347,  June,  1917. 
3  Sellards :  Johns  Hopkins  Hosp.  Bull,  xxv,  101,  1914. 


400  INFANT  FEEDING. 

pleted  in  the  office.  An  alkaline  reaction  of  the  urine 
can  be  brought  about  in  normal  infants  by  administering 
2  to  3  Gm.  of  bicarbonate,  and  in  older  children  and 
adults  by  5  Gm.,  usually  within  an  hour  after  adminis- 
tration, this  will  change  the  indicator  purple.  In  acid- 
otic  states  four  to  ten  times  as  much  is  necessary,  be- 
cause first  the  bicarbonate  given  must  replenish  the 
depleted  alkali  of  the  blood  and  tissues,  before  being 
excreted  in  the  urine. 

Another  method  devised  by  Sellards1  consists  essen- 
tially in  precipitation  of  the  proteins  from  a  small  quan- 
tity of  blood  and  adding  a  drop  of  phenolphthalein  in- 
dicator to  the  evaporated  filtrate.  In  acidosis,  instead 
of  a  deep  red  color,  a  pink  or  no  color  is  present. 

Tests  for  acetojiuria  only  apply  to  certain  special 
varieties  of  acidosis.  (Acetone-body  acidosis.)  The 
presence  of  such  bodies  are,  however,  not  sufficient  evi7 
dence  when  taken  alone  for  diagnosis  of  acidosis;  the 
reverse,  however,  holds  true  in  that  their  absence  does 
not  exclude  its  presence. 

Again,  in  special  types  of  acidosis  (increased  produc- 
tion of  organic  acids  or  ingestion  of  strong  mineral 
acids),  there  is  an  increased  excretion  of  ammonia  com- 
bined with  these  acids.  Consequently,  a  quantitative  esti- 
mation of  the  ammonia  co-efficient  in  the  twenty-four 
hour  urine  is  a  valuable  test  for  acidosis.  It  should,  how- 
ever, be  remembered  that  in  the  presence  of  nephritis  the 
ammonia  excretion  may  be  normal.2 

The  first  three  methods  described  are  those  most  prac- 
tical for  routine  clinical  investigation. 

Prognosis.  The  prognosis  varies  with  the  pre- 
cipitating etiological  factors,  the  severity  of  the  acidosis, 
and  upon  the  underlying  constitutional  conditions.  The 
result  obtained  is  dependent  first  upon  our  success  in 
the  removal  of  exciting  factors;  second  the  overcoming 


1  Sellards :  Ibid. 

2  Henderson,   Y. :  Arch.   Internal   Med.,  xvi,   109,   1915. 


ACIDOSIS.  401 

of  the  intoxication ;  and  third,  so  far  as  possible  the  re- 
lieving, or  when  possible,  removal  of  the  underlying 
factors.  The  early  relief  of  starvation,  by  the  institu- 
tion of  the  proper  diet,  counteraction  of  infection,  and 
the  neutralization  of  the  acetone  bodies,  is  all  that  is 
usually  necessary  in  the  mild  types  secondary  to  starva- 
tion and  infection.  In  children  suffering  from  recurrent 
vomiting,  sources  of  focal  infection  should  be  removed. 
In  the  acute  types  associated  with  diarrhea  the  prognosis 
is  grave.  Diabetes  and  chronic  nephritis  must  always 
be  reckoned  with  as  extremely  serious  factors.  In  cases 
of  acute  nephritis  of  moderate  severity  the  prognosis  is 
better. 

Treatment.  The  treatment  of  acidosis  must  first  be 
directed  to  the  prevention  of  a  further  production  of 
more  acids;  second,  to  replenishing  the  alkali  reserve; 
third,  to  the  elimination  of  the  acids  and  their  salts ; 
and  fourth,  to  the  treatment  of  the  underlying  factors, 
whether  they  be  acute  infections,  starvation  or  organic 
diseases. 

Water  Administration.  Large  quantities  of  water 
should  be  administered  by  mouth,  if  it  is  tolerated. 
When  not  retained,  subcutaneous  or  intraperitoneal  ad- 
ministration of  normal  saline  or  Ringer's  solution  is  to 
be  recommended,  the  latter  as  often  as  every  six  hours, 
if  necessary,  during  the  early  treatment.  The  total  quan- 
tity of  all  fluids  given  should  be  recorded  daily  and  every 
effort  made  to  administer  maximum  quantities. 

In  the  presence  of  acetone  body  acidosis  glucose  should 
be  given  in  all  cases  except  those  due  to  diabetes.  Three 
methods  of  administration  are  available:  by  mouth,  rec- 
tum, or  intravenously.  By  mouth,  a  5  to  10  per  cent. 
solution  may  be  administered  every  two  to  four  hours, 
in  quantities  depending  upon  the  age  of  the  child  and  the 
tolerance  of  the  gastro-intestinal  tract.  By  rectum,  a  5 
per  cent,  solution  is  best  employed,  which  may  be  ad- 
ministered intermittently  at  intervals  of  three  or  four 

26 


402  INFANT  FEEDING. 

hours,  quantities  varying  from  60  to  120  mils  (two  to 
four  ounces)  being  used,  or  in  young  infants  and  older 
children  who  are  not  too  restless  the  drip  method  may 
be  used.  When  there  is  a  tendency  to  return  the  glucose 
solution  it  may  be  necessary  to  compress  the  buttocks 
for  at  least  one-half  hour  after  each  administration.  A 
careful  record  should  be  kept  of  all  solutions  adminis- 
tered by  this  method  and  so  far  as  possible  the  retained 
fluid  estimated.  In  most  cases  a  liter  can  be  adminis- 
tered in  the  course  of  twenty-four  hours.  For  intra- 
venous use,  5  or  10  per  cent,  of  glucose  in  Ringer's  or 
normal  saline  solution  may  be  used,  depending  upon  the 
size  of  the  child,  from  60  mils  in  small  infants,  to  300 
mils  in  older  children,  may  be  injected  at  one  time,  to  be 
repeated  as  indicated. 

Intraperitoneal  Injection.  For  this  purpose  equal 
parts  of  4  per  cent,  glucose  solution  and  Ringer's  solu- 
tion may  be  used,  making  a  2  per  cent,  glucose  and  0.40 
per  cent,  saline  solution.  Stronger  solutions  are  hyper- 
tonic.  Fifty  to  500  mils  may  be  administered  by  the 
gravity  method. 

Alkali  Therapy.  In  our  experience  we  have  not  fav- 
ored the  use  of  alkalies  in  the  types  of  acidosis  due  to 
concentration  of  ketone  acids  and  this  agrees  with  the 
more  recent  experiences  of  Marriott,1  Gamble,2  and 
Schloss.3  Glucose  rather  than  bicarbonate  is  the  logical 
agent  in  the  treatment  of  non-diabetic  ketosis.  The 
same  is  true  of  the  lactic  acid  type.  Marriott  found  that 
when  sodium  bicarbonate  is  given,  the  amounts  of  sodium 
and  sodium  ions  in  the  blood  are  increased  and  this  in- 
crease disturbs  the  balance  between  the  sodium,  calcium 
and  magnesium  ions.  If  administered  sodium  bicarbo- 
nate should  be  given  by  mouth  or  intravenously.  By 

1  Marriott,  W.  McKim :  Personal  communication. 

2  Gamble,  J.  L.,  Ross,  S.  G.,  and  Tisdall,  F.  F. :  Transactions 
Amer.  Fed.  Society,  1922. 

3  Schloss,  O.  M. :  Trans.  Amer.  Fed.  Society,  1922. 


ACIDOSIS.  403 

mouth  from  1  to  2  grams  may  be  given  at  four-hour  in- 
tervals, dissolved  in  water.  For  intravenous  use  a  2  per 
cent,  solution  is  best  employed  as  it  is  isotonic  with  the 
blood.  The  same  amounts  of  solution  can  be  adminis- 
tered intravenously  as  recommended  for  the  administra- 
tion of  glucose. 

Rowland  and  Marriott  found  that  the  simplest  indica- 
tion that  sufficient  alkali  has  been  administered  is 
evidenced  by  shifting  of  the  reaction  of  the  urine  to 
normal.  When  it  becomes  amphoteric  or  alkaline  to 
litmus,  we  may  consider  that  a  slight  excess  has  been 
given.  Further  administration  should  then  be  withheld 
unless  the  urine  again  becomes  more  acid  than  normal. 
When  the  carbon  dioxide  tension  of  the  alveolar  air  is 
above  30,  recovery  is  usually  spontaneous  and  soda  is 
unnecessary.  Edema,  tetany  and  even  convulsions  have 
been  noted  following  the  administration  of  large  doses  of 
soda,  more  especially  in  young  infants.  These  usually 
disappear  with  the  cessation  of  the  soda  medication.1 

Diet.  While  the  administration  of  glucose  as  recom- 
mended may  carry  the  patient  over  the  first  emergency 
period,  insufficient  amounts  of  carbohydrate  are  given 
in  this  way  to  meet  its  needs.  Efforts  should  therefore 
be  directed  toward  the  further  administration  of  carbo- 
hydrates by  mouth  as  soon  as  the  condition  of  the  stom- 
ach permits.  After  a  short  period  of  rest,  the  time  of 
which  will  be  indicated  by  the  ability  of  the  stomach  to 
retain  inert  fluids,  which  in  most  instances  is  not  over 
six  to  twelve  hours,  further  administration  of  sugars 
and  cereals  should  be  begun.  Thick  cereal  pastes,  to 
which  cane  sugar  or  maltose  dextrose  compounds  have 
been  added,  are  usually  best  retained.  They  may  be 
given  in  small  quantities  at  two-hour  intervals,  or  at 


1  The  treatment  for  convulsions  due  to  an  excess  of  sodium 
ion  in  the  body  consists  in  pushing  water  and  the  administration 
of  magnesium  sulphate  intramuscularly  or  subcutaneously.  (See 

Spasmophilia.) 


404  INFANT  FEEDING. 

longer  intervals  with  the  administration  of  corn  or  maple 
syrup,  or  honey  in  teaspoon ful  or  larger  amounts. 
Malted  milk  is  often  well  taken.  Milk  chocolate  and 
plain  candy,  such  as  caramels,  are  valuable  and  are 
usually  well  taken  by  children  who  have  eaten  them 
previously  and  have  a  liking  for  them.  Various  plain 
wafers  sold  on  the  market  may  be  tried  on  the  second 
day.  Fruit  juices  and  sirups,  more  especially  orange 
juice,  should  be  given  in  small  quantities.  If  orange 
juice  is  retained,  larger  quantities,  diluted  with  sweetened 
water,  should  be  given  and  continued.  Skim  milk  or, 
better,  skim  buttermilk  can  usually  be  given  by  the  third 
day.  Whole  milk  and  fats  should  be  withheld  until  the 
child  is  convalescent. 

Medical  Treatment.  About  the  only  conditions  re- 
quiring further  medication  are  gastric  and  intestinal  dis- 
tention  and  the  retention  of  decomposing  food  in  the 
intestinal  tract,  vomiting  and  syncope. 

To  clear  the  intestinal  tract  milk  of  magnesia  or  some 
other  mild  saline  laxative,  together  with  enemata,  are 
best.  For  vomiting  in  the  presence  of  gastric  distention 
lavage  with  a  weak  bicarbonate  solution  is  often  most 
beneficial.  Small  doses  of  carbolic  acid  (%  to  % 
minim.),  administered  at  two-hour  intervals  for  three 
or  four  doses,  together  with  tincture  opii  camphorata 
for  the  relief  of  vomiting  and  restlessness,  are  indicated. 
In  the  presence  of  syncope  it  may  be  necessary  to  ad- 
minister cardiac  and  respiratory  stimulants. 


PART  IX. 

Anemias  of  Infancy. 


A  PROPER  knowledge  of  the  normal  blood  picture  in 
early  life  is  necessary  in  order  to  recognize  pathological 
changes  in  the  anemias. 

In  the  blood  of  the  new-born  we  find  the  following: 

The  hemoglobin  ranges  from  110  to  140  per  cent,  as 
a  rule.  The  erythrocytes  are  increased  to  from  five  to 
seven  million,  or  over. 

These  findings  begin  to  decrease  usually  by  the  fourth 
dav  and  toward  the  end  of  the  first  month  the  hemo- 
globin content  and  erythrocytes  have  arrived  at  the  usual 
level  of  infancy.  Nucleated  reds  may  be  present  up  to 
the  third  to  sixth  day.  The  leucocytes  are  often  increased 
up  to  30,000,  averaging  70  per  cent,  polymorphonuclears 
and  about  20  per  cent,  lymphocytes.  Within  a  few  days 
the  proportions  quoted  below  as  averages  for  infancy 
are  more  nearly  approximated.  Myelocytes  may  be 
present  for  a  few  weeks. 

In  the  infant's  blood  we  find  the  following: 

A  slight  decrease  of  erythrocytes  and  hemoglobin  be- 
low the  adult  level,  may  be  present.  The  red  cells  range 
from  4.5  to  5.5  million;  the  hemoglobin  from  70  to  95 
per  cent. 

The  leucocytes  average  about  12,000  or  13,000.  There 
is  a  preponderance  of  lymphocytes  (60  per  cent,  as  com- 
pared with  30  per  cent,  at  the  15th  year),  and  a  small 
number  of  polymorphonuclears  (30  per  cent,  as  com- 
pared with  70  per  cent,  at  the  15th  year).  The  transi- 
tionals  average  between  8  and  10  per  cent.  The  reversal 
of  these  percentages  occurs  by  the  6tli  year. 

(405) 


406  INFANT  FEEDING. 

Definition.  Anemia  is  characterized  by  a  decrease  of 
the  erythrocytes  or  hemoglobin,  or  both,  in  the  blood. 
The  hemoglobin  has  the  most  important  function  of  the 
blood  elements,  namely,  carrying  oxygen,  and  so  its  de- 
termination affords  the  most  important  method  for  ascer- 
taining the  functional  capacity  of  the  blood.  Not  "infre- 
quently infants  have  a  pale  appearance  and  are  seem- 
ingly anemic,  but  an  examination  of  their  blood  reveals 
a  normal  red  count  and  hemoglobin  content;  this  phe- 
nomenon may  be  ascribed  to  an  angiospastic  pallor  of 
the  skin. 

Etiology.  Anemia  may  develop  from  any  of  the  fac- 
tors producing  it  in  the  adult,  but  it  tends  to  follow  in 
the  wake  of  less  severe  causes  and  there  is  a  tendency 
to  more  rapid  recovery  in  the  absence  of  constitutional 
anomalies.  Probably  the  most  frequent  causes  of  ane- 
mia in  infants  are  nutritional  disturbances,  directly  or 
indirectly  due  to  faulty  dietary  and  iron  metabolism. 
Rickets  goes  hand  in  hand  with  this  group  of  anemias. 
Especial  stress  will  be  placed  upon  this  group  in  the  dis- 
cussion because  of  its  relevant  bearing  upon  nutritional 
disorders  in  infancy.  Other  common  causes  of  infan- 
tile anemia  are  infections,  both  acute  and  chronic,  and 
hemorrhagic  conditions. 

A  convenient  working  etiological  classification  of  the 
causes  of  anemia  in  infancy  follows: 
1.  Congenital    conditions    resulting    in    defective    blood 

formation. 

Diseases  of  the  mother  during  pregnancy,  due  to 
improper  diet,  eclampsia,  syphilis,  tuber- 
culosis, diabetes,  etc. 

Prematurity  and  other  conditions  with  resulting 
hypofunction  of  the  hematopoietic  system. 
Developmental  defects  in  the  blood-making 
organs  and  glands  of  internal  secretion 
(aplastic  anemia,  cretinism). 


ANEMIAS  OF  INFANCY.  4Q7 

2.  Primary  Hemorrhage. 

3.  Acquired. 

A.  Conditions  resulting  in  diminished  blood  forma- 

tion: 

Due  to  improper  hygiene,  with  resulting  dis- 
turbances of  nutrition; 

Due  to  dietetic  errors  (unduly  prolonged 
lactation),  (athrepsia,  rickets  and  scurvy)  ; 

Diseases  of  the  hematopoietic  system  (per- 
nicious anemia,  splenic  anemias,  leuke- 
mia). 

B.  Increased  blood  destruction,  due  to  toxic  causes : 

Bacterial  toxines  (acute  and  chronic  infec- 
tions) ; 

Parasitic  toxines; 

Endogenous  toxines  (nephritis,  hemolytic 
jaundice)  ; 

Chemical  poisons  (arsphenamin,  phosphorus, 
mercury)  ; 

Roentgen  rays. 

C.  Secondary    hemorrhages,    due    to    degenerative 

blood-vessel  changes  as  a  result  of  the  causes 
enumerated  in  Group  3. 

Diseases  of  the  mother  and  fetus,  tending  to  prema- 
ture birth,  have  a  direct  influence  on  the  postpartum 
blood  findings.  The  blood  pictures,  however,  vary  con- 
siderably, depending  upon  the  etiological  factors  involved. 
There  usually  is  a  predominance  of  the  regenerating 
blood  cells  which  may  be  of  the  embryonal  or  post- 
embryonal  type. 

The  characteristic  type  of  cells  produced  by  the  blood- 
forming  tissues  in  the  fetus  are  as  follows,  normally 
macrocytes,  myelocytes  and  megaloblasts,  and  are  pro- 
duced by  the  fetal  blood-forming  tissues.  Incomplete 
types  of  cells,  such  as  the  microcytes,  poikilocytes,  poly- 
chromatophiles,  and  normoblasts,  may  be  found  in  both 
the  embryonal  and  post-embryonal  stages.  In  the  infant 


408  INFANT  FEEDING. 

whose  immature  tissues  have  only  recently  been  of  the 
fetal  type,  a  reversion  to  embryonal  blood  cells  is  a  com- 
mon finding  in  the  anemias  of  even  moderate  severity, 
and  is  of  much  less  significance  than  of  the  same  find- 
ings in  adults. 

Anemia  in  the  mother  during  pregnancy  is  a  cause 
of  anemia  in  the  fetus  at  birth.  This  condition  in  the 
mother  may  result  from  improper  diet,  a  severe  acute 
disease  suffered  during  pregnancy,  or  from  constitutional 
diseases  of  the  mother,  as  syphilis,  tuberculosis,  nephri- 
tis, etc. 

Striking  is  an  anemia  which  develops  quite  regularly 
in  prematures  during  the  first  three  months  of  life.  In 
contrast  to  full  term  infants,  in  the  prematures  there  are 
a  greater  number  of  nucleated  red  blood  corpuscles,  a 
more  frequent  appearance  of  myelocytes  during  the  first 
days  of  life,  and  a  lesser  absolute  and  relative  leucocy- 
tosis.  There  is  also  a  distinct  and  very  early  hemo- 
globin impoverishment  of  the  blood,  which  reaches  its 
maximum  in  about  the  third  to  the  fourth  month.  In 
the  premature  and  twins  it  may  fall  rapidly  to  50  per 
cent,  or  lower.  This  anemia  is  usually  of  the  chlorotic 
type,  the  color  index  being  usually  0.4  to  0.6.  These 
infants  develop  a  severe  secondary  anemia  following  in- 
fections, etc.,  much  more  readily  than  full  term  infants, 
even  in  the  later  months  of  the  first  year.  Kunckel1 
believed  that  the  chlorotic-like  anemia  of  prematures 
was  due  to  a  disturbance  in  the  hemoglobin  metabolism 
as  well  as  a  deficient  iron  storage.  Lichtenstein2  be- 
lieved it  due  to  a  hypoplastic  condition  resulting  from 
insufficiency  of  the  hematopoietic  organ.  Hugounenq-0> 
has  shown  that  the  greater  proportion  of  the  iron  is  de- 
posited in  the  fetus  during  the  last  three  months  of  preg- 
nancy. The  premature  therefore  fails  to  get  the  required 


1  Kunckel :  Zeitschr.  f.  Kinderh.,  vol.  13,  1915,  101.  - 

2  Lichenstein :  Svenska,  La  Karesa  As   Kapets   Handlinger,  43, 
No.  4,  1917. 

3  Hugounenq :  Jahrb.  f.  Kinderh.,  51,  121. 


ANEMIAS  OF  INFANCY.  4Q9 

amount  of  iron  deposited  in  its  liver  (iron  depot). 
Twins  must  divide  the  iron  which  the  mother  can  fur- 
nish and  so  also  have  a  congenital  deficiency. 

Congenital  hypoplasia  and  imperfect  development  of 
the  bone  marrow,  which  prevents  the  hematopoietic  tis- 
sues from  properly  functioning  and  producing  sufficient 
vascular  elements,  may  cause  a  distinct  condition  (aplastic 
anemia)  or  merely  be  a  contributing  cause  in  the  de- 
velopment of  various  anemias  in  infants.  Probably  the 
reason  some  children  develop  severe  forms  of  anemia 
and  others  only  a  slight  degree  under  the  same  condi- 
tions, lies  in  a  constitutional  weakness  of  the  blood  pro- 
ducing organs  of  the  former.  Instances  have  occurred 
in  which  several  children  in  the  same  family  have  pos- 
sessed hematopoietic  organs  which  were  not  capable  of 
functioning  sufficiently,  death  or  severe  anemias  result- 
ing. It  is  reasonable  to  assume  that  there  may  be  con- 
genitally  deficient  bone  marrow  just  as  there  is  congeni- 
tally  deficient  thyroid. 

In  infantilism  and  congenital  anomalies  of  the  glands 
of  internal  secretion  (cretinism)  anemias  are  usually 
marked.  In  the  former  deficient  development  of  bone 
and  bone  marrow  is  cause  enough  for  the  anemia  accom- 
panying these  conditions. 

Anemias  following  hemorrhage  are  of  the  secondary 
type  with  a  tendency  to  reversion  to  the  embryonal  blood 
picture.  The  most  common  causes  of  early  blood  loss 
in  infants  are  bleeding  from  the  cord  and  intracranial 
vessels.  Somewhat  later  melena,  hemophilia  and  sepsis 
may  become  evident  causes,  and  in  the  later  months  pur- 
pura  and  scurvy  must  be  considered. 

Faulty  hygienic  surroundings  may  alone  cause  con- 
siderable anemia ;  however,  there  are  usually  other  asso- 
ciated factors. 

Lack  of  "mothering"  and  institutional  overcrowding 
predispose  to  secondary  infections. 


410  INFANT  FEED-ING. 

As  mentioned  previously,  nutritional  disturbances  are 
the  cause  of  the  largest  percentage  of  anemias  in  early 
life.  There  is  nothing  specific  about  the  degree  of  ane- 
mia which  a  nutritional  disturbance  will  cause.  In  some 
cases  a  severe  degree  of  anemia  will  develop  with  a 
severe  nutritional  disturbance,  in  others  the  anemia  will 
be  slight  and  vice  versa.  From  about  the  seventh  month 
to  the  end  of  the  second  year  (at  the  end  of  the  nursing 
period)  there  are  more  anemias  with  relatively  grave 
blood  pictures  than  at  any  other  age.  It  appears,  there- 
fore, that  there  is  a  predisposition  toward  a  functional 
insufficiency  of  the  hematopoietic  system  at  this  age 
which  predisposes  to  anemias.  This  is  somewhat  analo- 
gous to  the  diseases  of  the  skeletal  and  nervous  system 
of  this  period,  namely,  rickets  and  spasmophilia.  Im- 
proper artificial  nutrition,  metabolic  and  gastro-intestinal 
disturbances  and  poor  hygienic  surroundings  probably 
play  an  important  role  in  the  etiology.  Premature  in- 
fants, twins  and  those  who  have  not  completely  recovered 
from  previous  hemorrhages  are  especially  predisposed. 

Faulty  feeding  may  produce  anemia  in  several  ways. 

First,  there  may  be  an  insufficient  amount  of  iron  in 
the  food.  The  new-born  has  an  iron  reserve  or  storage 
in  his  tissues  of  which  the  liver  is  the  most  important 
depot,  which  is  highest  at  birth  and  then  gradually  falls 
until  a  minimum  is  reached  at  the  end  of  the  lactation 
period.  This  iron  reserve  prevents  an  iron  deficiency 
while  the  infant  is  being  fed  on  iron-poor  milk.  How- 
ever, if  the  iron-deficient  food  is  fed  over  too  prolonged 
a  time,  without  the  addition  of  mineral  rich  food  to  the 
diet,  an  anemia  is  prone  to  develop.  Naturally,  in  some 
infants  this  condition  develops  sooner  than  in  others, 
depending  upon  the  original  amount  of  stored  iron  sur- 
plus and  the  demand  upon  this  reserve. 

Second,  faulty  feeding  leading  to  chronic  functional 
intestinal  and  metabolic  disturbances  may  cause  anemia. 
This  may  be  due  to  lack  of  absorption  of  enough  food. 


ANEMIAS  OF  INFANCY.  4^ 

In  most  conditions  of  poor  or  impaired  nutrition  all  the 
organs  of  the  body  suffer  to  some  extent.  Thus  the 
bone  marrow  may  function  deficiently  under  these  cir- 
cumstances and  produce  fewer  erythrocytes,  or  erythro- 
cytes  deficient  in  hemoglobin. 

Improper  feeding  may  result  in  certain  severe  nutri- 
tional disorders,  as  rickets  and  scurvy.  In  these  condi- 
tions the  more  or  less  severe  anemia,  which  always 
accompanies  them,  may  be  due  to  the  same  etiologic 
factors  (poorly  balanced  diet,  improper  hygiene,  etc.) 
or  result  from  the  diseases  themselves  or  both.  Thus 
the  hemorrhages  in  scurvy  may  lead  to  anemia  and  the 
pathology  in  the  bone  marrow  of  rickets  interfere  with 
its  hematopoietic  function. 

Of  the  causes  of  the  primary  anemias  little  positive 
information  is  at  hand.  They  are,  in  all  probability,  toxic 
in  nature  with  a  secondary  effect  on  the  blood-making 
organs,  and  may  be  exogenous  or  endogenous  in  origin. 

The  bacterial  toxines  are  second  only  in  importance  to 
the  nutritional  disturbances  as  etiological  factors  in  the 
production  of  secondary  anemias.  Among  the  most  im- 
portant of  the  acute  infections  are  diphtheria,  scarlet 
fever,  tonsillitis,  pyelitis  and  otitis,  and  septic  infections. 
Among  the  chronic,  tuberculosis  and  syphilis  play  the 
most  important  role  in  infancy.  Parasitic  and  chemical 
toxines  are  of  far  less  importance  in  infancy  than  in 
older  children,  except  those  following  arsenical  poisoning. 

Among  the  endogenous  toxines,  those  resulting  from 
nephritis  are  frequent  causes  of  secondary  anemias. 

Iron  Metabolism.  The  iron  content  of  both  human 
and  cow's  milk  is  small  and  not  sufficient  to  meet  the 
requirements  of  the  developing  infant.  However,  there 
is  an  iron  depot  in  the  liver1  in  which  is  deposited 
enough  iron  by  the  time  of  birth  to  last  until  the  infant 
can  digest  foods  containing  iron.  If  this  original  supply 
is  abnormallv  small  (as  in  prematures,  etc.)  or  there  is 


Burse :  Zeitschr.  f .  Physiol.  Chemic.,  xiii,  399,  1889. 


412  INFANT  FEEDING. 

an  unusual  drain  upon  it  (as  in  hemorrhages,  infections, 
etc.),  the  supply  may  be  used  up  before  iron-containing 
foods  are  added  to  the  diet. 

Human  milk  contains  0.00015  per  cent,  of  iron  and 
cow's  milk  about  0.0007  per  cent.  Iron  is  absorbed  by 
the  small  intestine  and  excreted  by  the  large  intestine. 
Inorganic,  as  well  as  organic  iron  is  easily  absorbed.  But 
the  fact  that  iron  given  per  os  is  absorbed  into  the  cir- 
culation and  excreted  into  the  large  bowel  is  not  proof 
that  iron  is  really  used  by  the  organism.  However,  the 
administration  of  iron  medication  per  os  has  a  markedly 
beneficial  effect  on  certain  types  of  anemia. 

In  100  Gm.  of  ash  in  the  newborn  there  are  about 
0.8  Gm.  of  Fe2C>3;  38  to  40  per  cent,  of  this  iron  is  in 
the  blood ;  the  remainder  is  deposited  in  the  tissues 
(Hugounenq).1  The  actual  amount  of  hemoglobin  in 
the  body  rises  from  birth,  but  the  amount  as  compared 
with  the  body  weight  diminishes.  The  amount  of  iron 
deposited  in  the  tissues,  especially  in  the  liver  of  the  new- 
born, diminishes  soon  after  birth.  In  other  words,  the 
iron  in  combination  with  hemoglobin,  or  the  hemo- 
chromogen  radical,  increases  from  birth,  but  the  iron  not 
so  combined  (reserve  iron)  diminishes.  It  is  thus  easy 
to  understand  why  the  new-born  should  have  such  a 
large  amount  of  hemoglobin  and  reserve  iron,  and  that 
this  hemoglobin  iron  should  increase,  for  the  relatively 
great  body  surface  in  the  new-born  requires  a  large 
amount  of  oxygen-carrying  material.  Therefore  a  large 
amount  of  hemoglobin  must  be  produced.  The  hemo- 
globin iron  is  increased  at  the  expense  of  the  non- 
hemoglobin  iron.2 

Symptoms.  There  are  no  special  subjective  symp- 
toms characterizing  anemia  in  infancy.  Many  of  the 
symptoms  present  can  be  attributed  to  the  condition  caus- 
ing the  anemia.  The  majority  of  cases  may  be  grouped 


1  Hugounenq :  Jahrb.  f.  Kinderh.,  51,  121. 

2  Schwarz,  H.  and  Rosenthal,  N. :  Arch.  Fed.,  37,  1,  1920. 


ANEMIAS  OF  INFANCY.  413 

into  two  more  or  less  defined  types.  The  thin  under- 
weight infants,  who  seem  never  to  have  thrived  from  the 
time  of  their  birth — they  are  especially  liable  to  nutri- 
tional disturbances  and  infections.  The  second  group 
may  be  but  little  under  weight  and  present  a  well  rounded 
appearance;  however,  on  closer  examination  they  show 
a  more  or  less  marked  pallor,  and  in  the  extreme  cases 
of  the  fat  type,  their  skin  is  of  a  greyish  or  waxy  yellow 
tint  and  at  times  seemingly  semitransparent.  The  mucous 
membrane  findings  are  of  varying  intensity  and  are  of 
the  same  degree  as  those  of  the  skin.  The  majority  of 
cases  belong  to  the  second  group  and  include  many  of 
the  premature  and  rachitic  infants  and  those  with  low 
grade  infections.  Edema  occasionally  appears  about  the 
face,  trunk  and  extremities  in  the  severe  forms.  The 
onset  may  be  sudden,  or  gradual,  depending  upon  the 
etiologic  condition,  i.e.,  sudden,  following  infections  and 
hemorrhages;  gradual,  following  nutritional  disturbances, 
or  again,  as  in  prematures,  it  may  be  present  from  birth. 
Anorexia,  listlessness  and  muscular  weakness  may  be 
present.  Occasionally  the  appetite  may  be  capricious. 
The  state  of  nutrition  also  varies  with  the  cause.  The 
infant  may  be  considerably  underweight  although  at 
first  appearance  this  may  not  be  evident.  There  may  be 
gastro-intestinal  disturbances.  Hemic  murmurs  are  not 
as  frequent  as  in  older  children  and  adults.  In  the  severe 
anemias,  petechise  may  occur  in  the  skin  and  mucous 
membrane,  but  severe  hemorrhages  are  unusual  except 
possibly  epistaxis.  More  severe  hemorrhages  may, 
however,  occur  following  ulceration  of  other  mucous 
membranes. 

Splenic  enlargement  associated  with  anemia  is  a  very 
frequent  finding  during  the  first  year  of  life  and  its 
presence  is  of  great  diagnostic  value.  Not  infrequently 
there  is  an  increased  consistency  with  only  moderate  en- 
largement and  again  in  the  presence  of  sepsis  and  other 
infections  there  may  be  a  considerable  enlargement  but 


414  INFANT  FEEDING. 

the  spleen  may  be  so  soft  that  it  is  difficult  to  palpate. 
The  spleen  is  usually  considerably  enlarged  in  the  severe 
secondary  anemias  from  all  causes.  It  may  decrease  in 
size  before  the  blood  itself  has  reached  normal  levels. 
A  large  hard  spleen  in  the  first  three  months  of  life 
should  lead  to  an  examination  for  the  presence  of  syph- 
ilis. 'Other  common  causes  of  splenic  enlargement  during 
the  first  six  months  are  septic  infection,  tuberculosis  and 
various  types'  of  subacute  infections.  The  anemias  due 
to  various  constitutional  diseases,  such  as  rickets  and 
status  thymico-lymphaticus,  are  usually  associated  with 
splenic  enlargement.  Th.e  most  marked  enlargements 
accompanied  by  anemia  occur  in  von  Jaksch's  anemia, 
the  leukemias,  Banti's  and  Gaucher's  diseases.  Hemo- 
lytic  jaundice  is  also  accompanied  by  enlargement  of  the 
spleen. 

The  enlargement  of  the  liver,  although  not  infrequently 
present,  is  rarely  a  predominating  feature  in  the  clinical 
picture. 

Hyperplasia  of  the  lymph  glands  is  directly  dependent 
upon  the  underlying  cause  of  the  anemia. 

Blood  Findings.  The  changes  in  the  blood  picture  are 
the  most  important  factors  in  the  differential  diagnosis 
of  the  anemias  of  infancy. 

In  the  simplest  secondary  anemias  resulting  from 
hemorrhage,  infections  (toxins)  or  nutritional  disturb- 
ances, there  is  usually  a  reduction  of  both  hemoglobin 
and  erythrocytes  to  about  the  same  degree.  In  the  more 
severe  forms,  anisocytosis,  poikilocytosis;  polychromato- 
philia  and  normoblasts  are  not  unusual.  Usually  very 
few  embryonal  (fetal)  blood  elements  are  found,  such 
as  megaloblasts,  macrocytes,  and  myelocytes.  The  leuco- 
cyte count  varies,  depending  on  the  causative  factor. 

Following  hemorrhage  a  relative  leucocytosis  is  usu- 
ally noted.  In  the  acute  infections  they  vary  according 
to  the  type  of  infection  and  the  ability  of  the  organism 
to  react.  Individual  infants  vary  greatly  in  the  response 


ANEMIAS  OF  INFANCY.  415 

of  their  hematopoietic  systems  to  the  same  type  of  infec- 
tions; in  the  acute  septic  infections  usually  an  absolute 
increase  in  the  neutrophiles  is  seen,  while  in  tuberculosis, 
syphilis  and  influenza  a  low  white  count  and  at  times  a 
leukopenia  with  an  absolute  increase  of  lymphocytes  may 
be  noted.  Subacute  and  chronic  focal  infections  often 
show  little  or  moderate  increase  in  the  total  count  with 
a  predominance  of  lymphocytes. 

The  so-called  chlorotic  type  of  anemia — the  common 
type  seen  in  prematures,  twins,  and  the  poorly  fed  in 
the  early  months  of  life — probably  has  a  similar  founda- 
tion in  many  instances  and  presents  the  following  blood 
changes:  The  hemoglobin  is  greatly  diminished  but  the 
red  count  rarely  falls  below  3,000,000  and  is  more  fre- 
quently between  4,000,000  and  5,000,000.  The  color 
index  is  usually  between  0.4  and  0.6.  The  leucocyte 
count  approximates  the  normal,  ranging  from  6000  to 
10,000.  There  is  a  varying  tendency  to  lymphocytosis 
at  times.  However,  this  should  not  be  misinterpreted 
because  of  the  normal  high  mononuclear  count  in  the 
young.  The  red  cells  only  occasionally  show  poikilo- 
cytosis  and  anisocytosis.  Nucleated  reds  are  rarely 
found.  Blood  platelets  range  between  200,000  and 
300,000,  the  blood  volume  tends  to  remain  normal  and 
the  spleen  is  usually  not  large.1 

In  the  type  described  as  Ton  Jaksch's  anemia,  a  con- 
dition occurring  in  infants  and  children,  a  marked  anemia, 
moderate  enlargement  of  the  liver,  and  great  enlarge- 
ment of  the  spleen  and  sometimes  hypertrophy  of  the 
superficial  lymph  nodes  are  present.  The  blood  picture 
is  characterized  by  a  great  diminution  in  the  red  cells  and 
the  hemoglobin,  and  a  persisting  leucocytosis  of  varying 
degrees.  Nucleated  red  cells  are  nearly  always  present, 
sometimes  in  large  numbers,  and  occasionally  myelocytes 
are  seen.  The  hemoglobin  is  usually  below  50  per  cent. 


1  Schwarz  and  Roscnthal :  Ibid, 


416  INFANT  FEEDING. 

and  may  be  as  low  as  15  to  20  per  cent.  The  red  cells 
are  generally  2,000,000  to  3,000,000  per  c.mm.,  but  may 
fall  to  1,000,000,  or  lower.  There  is  a  high  grade  aniso- 
cytosis,  poikilocytosis  and  polychromatophilia.  The  leu- 
cocytosis  usually  ranges  between  15,000  and  50,000.  The 
small  lymphocytes  are  usually  greatly  increased  more 
especially  in  the  cases  secondary  to  nutritional  disturb- 
ances. Occasionally  this  picture  is  reversed  in  the  pres- 
ence of  infection.  The  condition  is  most  frequently 
associated  with  rickets,  but  whether  cause  or  effect  or 
concomitant  is  not  known.  It  is  most  common  during 
the  sixth  to  the  fifteenth  month,  the  age  at  which  rickets 
is  most  frequently  seen  in  the  active  stages.  It  is  rare 
in  the  breast-fed  and  well-nourished  infants.  Syphilis 
and  possibly  tuberculosis  are  believed  to  play  a  role  in 
some  of  the  cases.  Upper  respiratory  infections,  chronic 
pyelitis,  endocarditis,  and  like  infections  may  cause  a 
similar  picture. 

Most  of  the  patients  show  a  definite  tendency  to  re- 
covery. The  prognosis  must  necessarily  be  dependent 
upon  the  underlying  cause  and  the  presence  of  secondary 
complications..  In  those  who  live,  the  abnormal  blood 
picture  may  persist  for  a  long  period  after  the  patient 
is  clinically  well.  Gratz1  regards  it  as  an  infantile  form 
of  Banti's  complex.  His  view  has  received  but  little 
support.  There  has  also  been  a  tendency  to  call  this 
condition  "anemia  splenica  infantum."  This  is,  however, 
undesirable,  as  in  its  present  use  "splenic  anemia"  is  a 
descriptive  term  which  is  applied  to  a  large  number  of 
unrelated  conditions.  For  practical  purposes  and  until 
the  condition  is  better  understood,  it  is  preferable  to 
speak  of  it  as  "von  Jaksch's  anemia,"  than  "anemia 
pseudoleukemica  infantum,"  the  name  originally  given 

1  Gratz :  Unter  dem  Bilde  der  Anemia  splenica  verlaufende  ex~ 
tra-medullare  Bildung  von  Blutzellen  bei  einem  3  jahrige  Kind., 
Zentralb.  f.  allg.  Pathol.  u.  pathol.  Anat.,  1909,  xx.  Cit.  by 
Stettner. 


ANEMIAS  OF  INFANCY.  417 

to  the  condition,  since  the  term  pseudoleukemia  has  since 
acquired  a  more  specific  usage  and  the  condition  to  which 
it  refers  is  in  no  way  related  in  so  far  as  is  known  to 
this  type. 

Pernicious  Anemia.  This  form  of  anemia  is  very  rare 
in  infancy.  Well  authenticated  cases  have,  however,  been 
reported.  The  anemia  is  of  the  hemolytic  type.  The 
red  blood  cells  are  greatly  decreased  in  number  and  the 
hemoglobin,  being  set  free,  results  in  a  marked  decrease 
in  its  content.  There  is,  however,  a  high  color  index  in 
which  this  blood  picture  is  different  from  that  seen  in 
any  of  the  other  types  of  anemia.  There  are  normoblasts 
present  and  a  high  percentage  of  megaloblasts.  The  red 
cells  are  altered  in  other  respects,  showing  poikilocytes, 
microcytes  and  macrocytes.  Leukopenia  is  present  in  the 
majority  of  cases  and  a  relative  lymphocytosis  of  above 
that  to  be  expected  in  infancy  is  usually  present.  In 
extremely  leukopenic  blood  a  noteworthy  finding  is  the 
abnormally  high  percentage  of  large  mononuclear  non- 
granular  cells.  Myelocytes  are  almost  always  present. 
The  spleen  and  lymph  glands  are  usually  not  much 
enlarged. 

A  plastic  or  hypoplastic  anemia  is  dependent  upon  a 
congenital  or  acquired  hypoplasia  of  the  bone  marrow. 
It  is  a  rare  condition  and  in  its  chief  characteristics  re- 
sembles pernicious  anemia  and  is  in  all  probability  a 
form  of  this  disease.  The  blood  picture  shows  little  effort 
on  the  part  of  the  organism  to  reproduce  the  blood  cells. 
It  is  characterized  by  a  marked  diminution  in  the  hemo- 
globin and  red  cells.  Regenerative  forms  of  the  blood 
cells  are  usually  absent  and  a  high  grade  leukopenia  is 
usually  present.  The  spleen  more  commonly  shows 
moderate  enlargement. 

Among  the  more  exceptional  types  of  anemia  seen  in 
the  young  and  which  are  always  associated  with  spleno- 
megaly are :  Gaudier 's  disease  or  primary  splenomegaly, 
in  which  the  greatly  enlarged  spleen  shows  masses  of 


418  INFANT  FEEDING. 

characteristic  large  vesicular  cells  with  small  eccentric 
nuclei,  which  block  the  sinuses  of  the  spleen.  Similar 
groups  of  cells  are  found  in  the  lymph  nodes,  liver  and 
bone  marrow.  It  is  characterized  clinically  by  chronic 
splenomegaly,  enlargement  of  the  liver  and  a  peculiar 
brownish  or  grayish  discoloration  of  the  skin.  The  ane- 
mia is  usually  of  the  chlorotic  type  and  is  more  often 
of  moderate  degree.  A  diminution  in  the  number  of 
white  cells  is  characteristic.  It  is  probably  congenital 
in  origin,  although  usually  not  recognized  until  late  in 
infancy  or  childhood. 

Hemblytic  icterus.  Two  types  have  been  described : 
The  familial  or  Minkowski  type,  which  is  often  seen  in 
several  members  of  the  same  family.  The  main  symp- 
toms are  an  enlargement  of  the  spleen  and  to  a  lesser 
degree  of  the  liver.  The  most  outstanding  symptom  is 
an  acholuric  jaundice.  Increased  fragility  of  the  red 
blood  cells  is  often  marked  and  this  condition  must  be 
classed  as  a  true  hemolytic  icterus. 

The  second  type,  which  is  known  as  the  acquired  or 
Hayem  type,  may  come  on  at  any  age  and  is  usually 
associated  with  a  considerable  anemia  and  a  decided  en- 
largement of  the  spleen  and  liver.  Fragility  of  the  red 
cells  and  acholuric  jaundice  are  constant  findings.  These 
conditions  usually  last  throughout  life  and  often  show 
little  effect  upon  the  general  health.  No  specific  lesion 
has  been  demonstrated  at  autopsy. 

Banti's  disease  or  complex  is  discussed  to  complete 
the  group  but  does  not  concern  us  in  infancy,  as  it  is  a 
disease  of  later  childhood  'and  adults.  Banti's  complex 
and  splenic  anemia,  as  commonly  described  in  the  litera- 
ture, are  probably  one  and  the  same  thing.  Moschcowitz1 
believes  that  it  is  due  to  a  fibre-genetic  toxin,  probably 
of  intestinal  origin,  which  attacks  the  organs  draining 
the  portal  area,  causing  primarily  a  fibrosis  of  the  spleen ; 


1  Moschcowitz,  Eli :  Jour.  Amer.  Med.  Assn.,  Ixix,  1045,  1917. 


ANEMIAS  OF  INFANCY.  419 

and  if  the  toxin  is  sufficiently  intense  or  the  patient  lives 
a  sufficiently  long  time,  it  causes  a  cirrhosis  of  the  liver. 
The  sclerotic  vascular  changes  in  the  mesenteric  vessels 
are  explainable  on  the  same  grounds.  Finally,  there  de- 
velops an  ascites  due  to  atrophic  changes  in  the  liver. 
The  course  of  the  disease  is  slow,  often  covering  a  period 
of  many  years,  with  a  gradually  increasing  weakness  and 
pallor  and  digestive  disturbances.  A  tendency  to  hemor- 
rhages with  a  moderate  anemia  of  the  chlorotic  type  is 
usually  present.  The  resistance  of  the  red  cells  is  un- 
changed and  signs  of  a  regenerating  bone  marrow,  as 
evidenced  by  nucleated  and  reticulated  cells,  are  slight 
or  absent. 

Lenkemias  while  rare  in  infancy  are  of  sufficient  fre- 
quency to  deserve  mention.  The  types  most  likely  to 
be  seen  are  the  acute  forms. 

Acute  lymphatic  leukemia  is  the  most  common  form 
in  early  life.  The  symptoms  are  usually  so  severe  and 
the  course  so  rapid  as  to  suggest  an  acute  infection.  In 
most  cases  there  is  a  history  of  a  preceding  infection, 
such  as  tonsillitis,  sinusitis,  alveolar  abscess,  acute  pul- 
monary infections,  multiple  abscesses,  osteomyelitis,  etc. 
Other  cases  develop  in  the  presence  of  existing  simple 
or  secondary  anemias,  in  the  course  of  nutritional  dis- 
turbances, rickets,  scurvy,  etc.  Congenital  syphilis  has 
been  described  as  a  predisposing  factor.  Leukemia  may, 
however,  occur  as  a  primary  disease  in  infants  previously 
healthy. 

The  onset  may  be  abrupt  with  several  general  symp- 
toms, as  fever  and  prostration;  or  it  may  be  more  grad- 
ual, resembling  a  low  grade  infection.  There  soon 
develops  a  generalized  glandular  swelling,  often  first 
noticed  in  the  cervical  region,  probably  because  the  glands 
are  more  visible  or  due  to  the  fact  that  they  may  be  first 
involved  when  the  source  of  the  infection  is  in  the  region 
of  the  upper  respiratory  tract.  However,  the  axillary, 
epitrochlear,  inguinal  and  femoral  glands  usually  soon 


420  INFANT  FEEDING. 

become  involved,  and  roentgenographic  studies  will  show 
involvement  of  the  tracheal  and  bronchial  glands  and  not 
infrequently  the  thymus.  The  glands  vary  greatly  in 
size,  from  that  of  a  pea  to  a  walnut.  They  show  little 
tendency  to  become  tender  and  rarely  suppurate.  The 
spleen  soon  becomes  enlarged,  more  often  moderately, 
rarely  reaching  the  size  seen  in  the  chronic  forms.  The 
liver  is  also  enlarged  in  most  of  the  cases.  Both  of  these 
organs,  as  well  as  the  other  parenchymatous  organs,  show 
a  marked  infiltration  with  lymphoid  tissue,  either  diffuse 
or  in  patches.  The  changes  in  the  bone  marrow  vary, 
being  slight  in  some  instances.  The  gums  become  swol- 
len and  the  findings  in  the  mouth  may  resemble  those 
of  a  severe  scurvy.  Bleeding  occurs  and  not  infrequently 
sloughing  of  the  gums,  tonsils  and  palate.  Subcutaneous 
hemorrhages,  petechial  or  larger  ecchymotic  areas,  to- 
gether with  bleeding  from  the  mucous  membranes  of  the 
nose,  stomach,  intestines  and  bladder,  usually  occur  dur- 
ing the  course  of  the  disease. 

The  blood  picture  varies  in  the  different  stages.  In 
many  instances  great  changes  are  noticed  from  day  to 
day.  At  times  there  will  be  noted  a  considerable  increase 
in  white  cells  and  this  may  change  within  a  few  hours 
to  a  leukopenia.  The  lymphocytes  dominate  the  blood 
picture,  often  reaching  from  90  to  as  high  as  100  per 
cent,  of  the  white  cells,  with  a  corresponding  reduction 
in  the  other  forms.  Most  cases  show  a  very  high  per- 
centage of  the  large  type  of  lymphocytes.  These  cells, 
however,  are  frequently  degenerate  and  offer  great  dif- 
ficulty in  staining  for  differentiation.  The  total  white 
count  usually  runs  from  25,000  to  100,000  cells  in 
infants.  At  times,  and  more  especially  toward  the  end 
of  the  disease,  they  may  almost  disappear.  The  hemo- 
globin may  be  reduced  to  10  to  30  per  cent,  and  the 
red  cells  to  1,000,000  to  2,000,000.  The  diminished 
coagulability  of  the  blood  accounts  in  part  for  the  great 
susceptibility  to  hemorrhage.  The  disease  is  usually  ac- 


ANEMIAS  OF  INFANCY.  421 

companied  by  an  irregular  temperature  curve  and  evi- 
dence of  myocardial  involvement. 

The  course  usually  covers  a  period  of  from  two  to 
four  weeks  from  the  time  of  its  recognition,  although 
some  cases  may  run  a  longer  course. 

Splenomyelogcnous  leukemia,  while  more  rapid  in  its 
course  in  the  young  is  less  acute  than  the  lymphatic  type 
and  is  an  exceptional  disease  in  infancy.  Anemia  and 
splenic  enlargement  are  usually  the  first  signs  to  be  noted. 
There  is  more  or  less  evident  involvement  of  the  liver. 
The  lymphatic  glands  rarely  attain  a  large  size  and  may 
not  be  visibly  involved.  Asthenia  is  marked  and  an 
early  manifestation,  and  is  associated  with  a  rapid,  weak 
pulse,  dyspnea  and  disturbances  of  the  digestive  tract. 
Hemorrhages  into  the  skin  and  mucous  membranes  may 
be  present  at  any  stage  of  the  disease.  The  total  white 
count  is  greatly  increased,  at  times  varying  between 
50,000  and  500,000.  The  polymorphonuclear  neutro- 
phils  are  greatly  increased,  although  at  certain  stages 
they  may  be  in  greater  part  replaced  by  myelocytes.  Both 
the  mono-  and  polymorphonuclear  types  of  eosinophils 
are  increased.  The  lymphocytes  are  increased,  the  small 
cells  oftener  predominating.  Increase  in  both  the  mono- 
and  polymorphonuclear  basophils  is  one  of  the  most 
characteristic  Findings  of  the  disease. 

The  course  of  all  forms  of  true  leukemias  of  infants 
is  toward  a  fatal  termination.  Most  of  the  cases  are 
complicated  by  secondary  infections. 

Prognosis.  In  the  anemias  of  infancy  the  prognosis 
is  dependent  upon  the  nature  of  the  cause  and  the  ability 
of  the  individual  infant  to  react.  In  the  milder  types 
associated  with  improper  diet,  poor  hygiene  and  rickets, 
with  removal  of  the  cause,  improvement  is  usually  rapid. 
In  those  following  acute  hemorrhage  of  moderate  de- 
gree, regeneration  is  usually  rapid,  unless  there  be  some 
underlying  constitutional  condition,  such  as  scurvy  and 
purpura,  when  the  prognosis  must  be  guarded.  In  the 


422  INFANT  FEEDING. 

acute  and  chronic  infections,  more  especially  diphtheria, 
tuberculosis  and  syphilis,  it  will  vary  with  the  severity 
of  the  infection,  the  individual  resistance  and  the  insti- 
tution of  proper  treatment.  The  same  may  be  said  of 
the  cases  following  genito-urinary  infections,  such  as  py- 
elitis  and  nephritis.  In  the  severe  types  of  anemia  asso- 
ciated with  embryonal  blood  pictures,  splenic  enlargement, 
and  grave  constitutional  involvement,  the  prognosis  is 
always  grave.  In  all  types  of  anemia  there  is  a  tendency 
toward  secondary  infection  due  to  lessened  immunity. 

Treatment.  The  treatment  must  be  directed  toward 
removing  or  curing  if  possible  the  exciting  etiological 
factors,  as  well  as  toward  remedying  the  existing  anemias. 

Prophylactically,  much  can  be  accomplished  toward 
preventing  certain  of  the  anemias  of  infancy.  A  com- 
plete clinical  study  of  the  patient  must  be  made,  including 
a  thorough  search  for  possible  focal  infections.  The 
mouth,  nose  and  throat,  sinuses,  respiratory,  digestive 
and  urogenital  tracts  must  be  carefully  investigated.  If 
any  focal  infection  is  found  it  must  be  thoroughly  eradi- 
cated. The  important  part  which  alveolar  abscesses  may 
play  in  the  secondary  anemias,  even  in"  infancy,  must  not 
be  overlooked. 

The  anemias  of  prematures  can  often  be  avoided  by 
proper  feeding,  the  early  administration  of  iron,  cod- 
liver  oil  and  orange  juice,  more  particularly  in  the  arti- 
ficially fed.  The  anemia  resulting  from  nutritional 
disturbances  can  be  prevented  by  a  well  balanced  diet 
which  includes  prophylactic  measures  for  rickets  and 
scurvy.  The  instituting  of  vegetable  soups  and  vegetable 
feeding  as  early  as  the  sixth  or  seventh  month,  be- 
fore the  iron  reserve  is  completely  exhausted,  is  to  be 
recommended. 

The  treatment  of  the  anemia  proper  consists  in  ar- 
ranging the  dietary,  providing  the  age  of  the  infant 
permits,  so  that  plenty  of  iron  containing  foods  are  given. 
Especially  valuable  are  green  vegetables,  vegetable  and 


ANEMIAS  OF  INFANCY.         .  433 

cereal  broths,  meat  juices,  and  eggs.  Bread  and  cereals 
should  be  limited  so  as  not  to  crowd  out  the  above.  Fruit 
juices  are  also  valuable.  Spinach  in  powdered  form  can 
be  added  to  the  milk  mixture  to  advantage  once  or  twice 
daily. 

Fresh  air,  sunlight,  sufficient  exercise  and  in  general 
proper  hygienic  surroundings,  are  of  tremendous  im- 
portance. Hydrotherapy  and  massage  may  often  be  used 
advantageously. 

Iron  and  arsenic  play  the  principal  role  in  the  medi- 
cation. A  convenient  form  of  iron  medication  is  ferri 
et  ammonii  citrate,  gr.  ss  to  gr.  iii,  or  the  saccharated 
carbonate,  grs.  i  to  v,  twice  daily.  In  severer  cases  the 
hypodermic  injection  of  iron,  arsenic,  or  iron  and  arsenic 
combinations  twice  a  week  are  recommended.  The  albu- 
minates  or  peptonates  of  iron  may  be  alternated  with  the 
inorganic  salts  where  the  treatment  must  be  long  con- 
tinued. It  should  be  remembered  that  there  is  a  pos- 
sibility of  over-medication  with  iron  and  that  the  stomach 
may  rebel  when  excessive  dosage  is  administered.  Liquor 
potassi  arsenitis,  in  1  to  3  minim  doses  three  times  daily, 
is  a  valuable  adjunct  to  iron  medication  but  the  period 
of  time  over  which  it  is  administered  should  be  limited. 
Organotherapy  and  the  administration  erf  bone  marrow 
have,  on  the  whole,  not  yielded  satisfactory  results. 

Blood  transfusion  often  proves  extremely  valuable  in 
the  severe  forms  of  anemia.  Intravenous  transfusion  is 
the  most  satisfactory,  but  good  results  have  followed 
intramuscular  injections  of  whole  blood.  Transfusions 
should  be  repeated  at  regular  intervals  in  severe  cases. 
The  most  that  should  be  expected  from  transfusion  is  a 
temporary  benefit  in  the  severe  cases  sufficient  to  bridge 
the  period  of  shock  and  the  time  necessary  to  the  thera- 
peutic effect  of  other  forms  of  medication.  Prolonged 
exposure  of  the  spleen  to  the  roentgen  rays,  with  proper 
protection  of  the  surrounding  tissue,  has  been  followed 
by  marked  improvement  in  a  number  of  our  cases. 


424  INFANT  FEEDING. 

In  acute  hemorrhage  and  some  of  the  hemorrhagic 
diseases,  physiological  salt  solutions,  or  better,  Ringer's 
solution,  intravenously  or  intramuscularly,  may  be  in- 
dicated and  in  the  former  method  of  administration  the 
addition  of  epinephrin  to  the  solution  is  a  valuable 
adjunct. 

Splenectomy  for  cases  of  von  Jaksch's  anemia,  with 
good  results,  are  reported  by  Giffin1  and  Stillman.2  Five 
operative  recoveries  with  apparently  lasting  improvement 
out  of  six  cases  are  reported  by  them.  With  a  tendency 
to  spontaneous  recovery  in  von  Jaksch's  anemia,  the  ad- 
visability of  subjecting  young  infants,  generally,  to  this 
operation  is  open  to  question. 


1  Giffin,  H.  Z. :  Annals  of  Surg.,  42,  676,  1915. 

2  Stillman,   R.   G. :  Amer'.  Jour,   of   Med.    Sciences,   xxx,    153, 
219,  1917. 


Appendix. 


PROPRIETARY   BABY   FOODS. 

IT  should  be  borne  in  mind  that  the  average  daily  cost 
of  many  of  the  proprietary  baby  foods  is  in  excess  of 
twenty-five  cents. 

For  practical  purposes  the  baby  foods  may  be  classed 
as  follows: 

GROUP  I.  Prepared  from  cow's  milk. 

1.  Condensed  milk  without  added  sugar. 

2.  Condensed     milk     with     added     sugar     (Borden's 

Eagle   Brand)    (F.,  8.85;   P.,  7.34;  milk-sugar, 
11.61;  cane-sugar,  42.9;  ash,  1.77;  water,  27.53). 

3.  Evaporated  milk  (St.  Charles)    (F.,  9.0;  P.,  7.82; 

milk-sugar,  11.19;  ash,  1.71;  water,  69.91). 

4.  Peerless  Brand  unsweetened  evaporated  milk  (F., 

9.27;  P.,  7.28;  milk-sugar,  9.99;  ash,  1.51;  water, 
71.82). 

5.  Carnation  Brand. 

6.  Lacta  Praeparata  (powder). 

7.  Mammala   (powder)    (F.,   12.12;  P.,  24.35;  milk- 

sugar,  55.34;  ash,  5;  moisture,  3.19). 

8.  Dryco  Brand  powdered  milk   (F.,  12.0;    P.,  34.0; 

milk-sugar,  44.0;  ash,  7.0;  moisture,  3.0). 

9.  Klim    (Merrell-Soule   Co.)    Powdered   milk— mar- 

keted as  whole  milk  powdered,  skim  milk  pow- 
dered, modified  milk  powdered.      . 
10.  Powdered  albumin  milk,  Hoos  albumin  milk  (pro- 
tein milk),  Merrell-Soule  protein  milk   (albumin 
milk). 

(425) 


426  INFANT  FEEDING. 

GROUP  II.     Foods  prepared  from  dried  cow's  milk  and 
modified  cereals.    To  be  diluted  with  water  only. 

(A)  Containing  much  unchanged  starch. 

1.  Nestle's   Food    (milk-sugar,   7.4;  maltose,    15.6; 

cane-sugar,  24.77;  starch,  17.31;  protein,  10.92; 
dextrin,  13.51;  fat,  5.63;  ash,  1.49;  water, 
3.37). 

2.  Anglo-Swiss. 

(B)  Starch   largely  converted  into   soluble   carbohy- 

drates, such  as  maltose  and  dextrin. 

1.  Horlick's  Malted  Milk  (F.,  8.5;  P.,  16.3;  dextrin, 

18.80;  maltose,  39.15;  lactose,  10.0;  sodium  bi- 
carbonate, 1.0). 

2.  Allenberry's  I  and  II.     (No.  I,  F.,  17.2;  P.,  10.6; 

maltose,  14.0;  dextrin,  10.0;  lactose,  42.0;  ash, 
3.0.)  (No.  II,  F.,  15.88;  P.,  9.90;  maltose, 
20.0;  lactose,  36.0;  dextrin,  13.0;  salts,  3.71.) 

GROUP  III.  Foods  prepared  from  modified  cereals  to  be 
used  with  fresh  cow's  milk. 

(A)  Starch  unchanged. 

1.  Flours   of   barley,  wheat,   rice,    corn,   oats,    soy 

beans,  etc.  (Barley  flour,  1  level  tablespoonful 
(98  grains)  to  12  ounces  water  equals  1.27 
starch  or  1.8  calories  per  ounce.) 

2.  Arrowroot. 

(B)  Starch  partially  dextrinized. 

1.  Barley  flour:    Robinson's,  Mead's,  Johnson's. 

2.  Imperial  Granum  (F.,  1.4;  P.  14.0;  carbohydrates 

(sol.),  1.8;  carbohydrates  (insol.),  73.5;  ash, 
0.39;  water,  9.0).  (Can  be  used  when  flour  ball 
is  indicated.) 

3.  Eskay's  Food   (contains  a  small  amount  of  egg 

albumin)  (F.,  1.0;  P.,  6.7;  carbohydrates  (in- 
sol.), 21.21;  carbohydrates  (sol.),  67.81; 
ash,  1.3). 


APPENDIX.  427 

4.  Denno's  Baby  Food   (F.,   1.79;  P.,   11.0;  cane- 

sugar,  15.2;  starch,  64.6;  ash,  1.12;  water, 
6.2). 

5.  Allenberry's    No.    Ill    (malted)     (F.,    1.05;    P., 

10.23;  carbohydrates  (sol.),  25.00;  maltose, 
16.5;  dextrin,  8.5;  carbohydrates  (insol.), 
60.01;  ash,  0.60). 

(C)   Starch     completely     changed     to     dextrin     and 
maltose : 

1.  Borcherdt's    Dri-Malt    Soup    Extract    (maltose, 

71.10;  dextrin,  13.50;  protein,  8.66;  ash,  2.94; 
moisture,  3.80).  Calories  per  ounce  by  weight 
equals  110.  It  is  a  laxative,  and  is  easily  di- 
gested because  of  the  high  maltose  and  potas- 
sium carbonate  (1.1  per  cent.)  contents. 

2.  Borcherdt's   Malt   Soup  Extract    (protein,  6.40; 

maltose,  57.57;  dextrin,  11.70;  ash,  2.54;  mois- 
ture, 21.79).  It  contains  1.1  per  cent,  potas- 
sium carbonate. 

3.  Borcherdt's  Dri-Malt  Soup  Extract  with  Wheat 

Flour.  Semi-liquid  malt  soup  extract,  to 
which  gelatinized  wheat  flour  has  been  added, 
and  the  whole  dried.  One  ounce  equals  110 
calories. 

4.  Borcherdt's  Malt  Sugar  (dry)    (maltose,  87  per 

cent.;  dextrin,  5  per  cent.).  One  ounce  equals 
120  calories.  The  following  table  will  give  a 
comparative  idea  of  the  relative  value  by  weight 
and  measure  of  Borcherdt's  liquid  and  dri-malt 
soup  extracts: 
16  Fluid  oz.  equal  19.5  oz.  dry  malt  powder  by  measure. 

1  Fluid  oz.  equals  1.2  oz.  dry  malt  powder  by  measure. 

1  Ounce  of  liquid  by  weight  equals  0.83  oz.  of  powder. 

1  Fluid  oz.  represents  90  calories. 

1  Ounce  of  powder  by  weight  represents  110  calories. 


428  INFANT  FEEDING. 

5.  Horlick's  Malt  Food  (contains  no  milk)  (F.,  1.40; 

P.,  12.06;  carbohydrates  (chiefly  maltose), 
81.97;  ash,  2.60;  water,  1.97.  Calories,  109.29. 
It  contains  1  per  cent,  of  potassium  bicarbonate. 

6.  Mellin's    Food    (F.,    0.16;    P.,    10.35;    maltose, 

58.88;  dextrin,  20.69;  carbohydrates  (sol.), 
79.57;  salts,  4.3;  water,  5.6).  Calories,  91.43. 
It  contains  2  per  cent,  of  potassium  bicarbonate. 

7.  Dextri-maltose    (Mead's    No.    1)     (maltose,    52; 

dextrin,  41;  water,  5;  sodium  chloride,  2).  No. 
2  (maltose,  53;  dextrin,  42;  water,  5).  No.  3 
(maltose,  52;  dextrin,  41;  water,  5;  potassium 
carbonate,  2). 

8.  Nahrzucker  (Sohxlet)   (F.,  0.03;  P.,  0.13;  mal- 

tose, 41.0;  dextrin,  53.3;  ash,  1.7;  water,  2). 

GROUP  IV.  Dry  casein. 

1.  Larosan  (Roche),  (calcium  caseinate). 

2.  Casec  (Mead),  (calcium  caseinate). 

3.  Protolac  (Dry  Milk  Co.),  (calcium  caseinate). 

GROUP  V.  Diastatic  ferments. 

1.  Diastoid    (Horlick's,  powder).     Maltose  72.91   per 

cent. 

2.  Diazyme  (Fairchild,  liquid),  a  good  product. 

GROUP  VI.  Peptonizing  powders. 

1.  Peptogenic  milk  powder  (Fairchild's). 

2.  Pepsin. 

GROUP   VII.  Rennet  powders    (precipitating  curd   in  a 
finely  divided  form). 

1.  Chymogen  (rennin  and  milk-sugar). 

2.  Pegnin  (rennin  and  milk-sugar). 

GROUP  VIII.  Powdered  vegetables. 
Carrot  (Beebe). 
Spinach  (Beebe). 

It  will  be  noticed  that  there  are  two  great  classes  of 
proprietary  infant  foods: 


APPENDIX.  429 

THE  FIRST.  (GROUPS  I,  II).  Those  containing  cow's 

milk. 

Sweetened  Condensed  Milks.  These  are  advertised  as 
complete  infant  foods.  All  of  them  are  quite  similar  in 
composition.  All  contain  large  amounts  of  cane-sugar. 
It  is  impossible  to  make,  by  simply  adding  water,  a 
properly  balanced  food  for  an  infant's  continuous  diet. 
A  dilution  to  give  a  rational  amount  of  proteins  and  fats 
has  a  large  excess  of  sugars,  and  one  to  contain  any 
amount  under  7  per  cent,  total  sugar  would  be  so  weak 
in  both  protein  and  fat  that  the  baby's  proper  growth 
would  be  very  seriously  interfered  with. 

Eagle  Brand  condensed  milk  contains:  fat,  8.85;  pro- 
teins, 7.34;  milk-sugar,  11.61;  cane-sugar,  42.90;  ash, 
1.77;  water,  27.5. 


TABLE. 


A  Well-known   Condensed  Milk,   Showing  the  Content 
of  Various  Dilutions.    Fats  and  Proteins  Deficient. 


Fat    

Full 
strength 
Per  cent. 

6.94 

6  parts 
water 
Per  cent. 

.99 

12  parts 
water 
Per  cent 
.53 

18  parts 
water 
Per  cent. 
.36 

Proteid 

8.43 

1.2 

.65 

.44 

Cane-sugar  . 
Salts   

..    50.69 
1.39 

7.23 

.17 

3.90 
.10 

2.67 
.07 

Water  ., 

31.30 

90.49 

94.80 

96.46 

The  Unsweetened  Evaporated  Milks.  They  are  made 
by  heating  the  milk  to  200°  F.,  and  then  transferring  it 
to  vacuum  pans,  where  it  is  maintained  at  a  temperature 
of  125°  F.,  until  sufficient  water  is  evaporated  to  bring 
the  product  to  the  required  condensation.  In  most 
products  this,  milk  is  about  double  strength. 

The  sugar  content  not  being  in  excess,  these  milks  can 
be  so  diluted  that  a  reasonable  amount  of  fat  and  protein 
can  be  obtained,  with,  however,  a  considerable  deficiency 
in  sugar;  this  relatively  low  amount  of  carbohydrate  can 
then  be  made  up  by  adding  sugar  (cane  or  maltose-dex- 
trin compounds),  much  the  same  as  is  done  with  cow's 


430  INFANT  FEEDING. 

milk.  Where  it  is  impossible  to  obtain  clean,  fresh  milk, 
evaporated  milk  can  be  used  with  good  success  as  a  tem- 
porary diet  in  traveling,  etc.  A  fresh  can  should  be 
opened  daily.  It  can  be  diluted  with  three  to  six  or  more 
parts  of  water,  or  cereal  water  and  sugar  in  some  form 
as  indicated;  however,  the  carbohydrates  contained  in 
the  formula  should  rarely  exceed  7  per  cent.  One  part 
of  milk  to  two  parts  of  diluent  plus  carbohydrates  is  the 
strongest  formula  in  which  it  is  ever  necessary  to  feed 
infants,  as  this  equals  .the  strength  of  whole  milk  with 
carbohydrate  added. 

Occasionally,  infants  with  a  very  weak  digestion  will 
thrive  on  the  evaporated  milk  where  all  other  methods 
fail,  if  the  food  is  started  in  high  dilution,  the  quantity  be- 
ing increased  as  the  infant  shows  improved  capacity. 

Because  of  the  repeated  heating  and  the  low  salt  con- 
tent, the  food  necessarily  loses  some  of  its  vital  require- 
ments, and  an  early  attempt  to  change  to  fresh  milk 
should  be  made  in  order  to  avoid  constitutional  disorders 
as  rachitis,  scurvy,  etc.  The  tendency  to  become  very 
fat  on  this  class  of  foods  is  proverbial,  but  this  is  not 
usually  associated  with  high  resistance  or  immunity  to 
infections,  and  these  infants  succumb  rapidly  to  the 
respiratory  and  intestinal  infections.  Unless  the  mother 
is  forewarned,  it  is  often  with  reluctance  that  she  can  be 
made  to  foresee  the  necessity  of  taking  her  baby  off  the 
food  which  agrees  with  it,  and  experiment  with  a  new 
and  occasionally  uncertain  formula. 

The  Powdered  Milk  Foods.  Mammala,  Honor  Brand, 
and  Merrill-Soule  Brand  are  fresh  milk  dried.  In  the 
two  former,  part  of  the  cream  has  been  removed.  All 
have  some  lactose  added.  They  find  their  most  impor- 
tant indication  as  an  occasional  substitute  feeding  in 
breast-fed  infants — first,  for  the  mother's  convenience, 
to  allow  her  recreation ;  secondly,  where  the  milk  of  the 
mother  is  insufficient,  and  one  or  two  regular  feedings 
are  indicated  temporarily  until  a  formula  of  fresh  milk 


APPENDIX.  431 

is  advisable,  or  while  traveling,  when  the  milk  supply  is 
uncertain;  and  thirdly,  those  containing  large  amounts 
of  maltose  (Horlick's)  can  be  given  once  daily  in  breast- 
fed infants  in  need  of  a  laxative. 

THE  SECOND  CLASS.  Those  to  be  used  in  conjunction 
with  fresh  cow's  milk.  In  this  class  belong  GROUPS  III 
and  IV.  These  give  us  a  far  more  rational  infant  food. 

GROUP  III.  (A)  The  unchanged  or  partially  dextrin- 
ized  starches  are  especially  to  be  used  in  solution  in  place 
of  boiled  water  as  diluents,  best  after  the  second  month. 
A  number  of  good  cereal  flours  can  be  purchased  on  the 
market. 

(B)  In  this  group  are  found  most  of  the  highly  ad- 
vertised and  detailed  baby  foods.     They  have  little  or 
no  advantage  over  the  plain  cereal  flours. 

(C)  These  are  especially  valuable  where  maltose  and 
dextrin  are  better  taken  than  cane-  or  milk-  sugar.    Dex- 
tri-maltose  (Mead's  No.  1  and  2)  and  Nahrzucker. 

DIRECTIONS    FOR    THE    PREPARATION 
OF    INFANT'S    FOODS. 

Tea. 

To  a  small  half-teaspoonful  of  fennel,  chamomile,  or 
"green"  tea  add  1  pint  of  boiling  water,  cover  with  a 
clean  dish,  and  steep  for  two  or  three  minutes,  or  till  the 
tea  is  of  a  light  yellow  color;  then  pour  through  a  clean 
sieve  or  muslin.  It  should  be  weak.  If  used  for  thirst 
only,  in  diarrheal  cases,  one-fourth  of  the  above  amount 
is  sufficient. 

Barley  Water.  , 

Soak  2  tablespoonfuls  of  washed  barley  (pearl)  in 
water  overnight;  pour  off  water,  add  1  quart  of  fresh 
water,  and  boil  down  to  1  pint  (2  hours).  Add  boiled 
water  to  make  1  pint,  if  necessary.  Strain  through  fine 
cloth.  Keep  in  ice-chest. 


432  INFANT   FEEDING. 

Oatmeal  and  Rice  Water. 

They  are  prepared  in  the  same  manner,  only  boiled 
more  slowly.  They  may  be  made  from  barley,  oatmeal, 
or  rice  flours  by  using  1  rounded  tablespoonful  to  1^ 
pints  of  water,  and  boiling  for  20  minutes  down  to  1 
pint,  in  an  open  stew-pan,  stirring  constantly.  (Ap- 
proximates 3  calories  per  ounce).  In  preparation  of  a 
feeding  formula  they  can  be  prepared  in  a  more  con- 
centrated form  if  indicated. 

Farina,  Cream  of  Wheat,  Oatmeal  and  Rice 
Flour  Gruels. 

To  make  six  ounces  use — 1  tablespoonful  cereal,  ^2 
cup  water,  ^  cup  milk,  1  pinch  salt.  Boil  for  thirty 
minutes  over  the  direct  flame  or  \l/2  hours  in  the  double 
boiler. 

To  Dextrinize  Barley  or  Oatmeal  Water. 

Cool  to  105°  F.,  add  1  teaspoonful  extract  of  malt, 
cereo,  liquid  taka-diastase  or  diazyme,  stir,  allow  to 
stand  for  15  minutes,  when  the  gruel  becomes  thin  and 
watery.  Add  a  pinch  of  salt,  stir,  only  to  mix,  cool, 
strain,  and  put  in  ice-chest. 

Flour  Ball. 

Tie  2  pounds  of  wheat  flour  in  a  cheese-cloth  bag,  and 
boil  in  2  quarts  of  water  for  five  hours.  Remove  from 
water;  place  in  oven  until  quite  brown  on  the  outside. 
This  will  require  from  two  to  three  hours  slow  baking. 
Break  open  and  throw  away  the  brown  shell;  the  re- 
mainder, the  baked  flour,  must  then  be  grated  into  a 
powder,  or  may  be  ground  in  a  mill. 

Albumin  Water. 

To  y2  cup  of  cold  boiled  water  add  the  white  of  1  fresh 
egg  and  a  pinch  of  salt.  Stir  very  thoroughly.  A  piece 


APPENDIX.  433 

or  two  of  artificial  ice  may  be  added  before  stirring. 
One-half  teaspoonful  of  sugar  and  orange  juice  may  be 
added,  if  not  contraindicated.  Barley  water  may  be  used. 

Albumin  Water  with  Beef  Extract. 

One-quarter  teaspoonful  of  beef  extract  may  be  added 
to  the  cold  water  before  adding  the  egg  albumin. 

White  of  Egg  and  Digested  Gruel. 

Whites  of  2  eggs  may  be  added  to  1  pint  of  dextrin- 
ized  barley,  oatmeal,  etc.,  gruels.  Stir  thoroughly. 

Pasteurization  of  Milk  Without  a  Thermometer. 

Place  milk  as  it  comes  from  the  dairy  (with  stopper 
removed  and  plug  of  sterile  cotton  inserted)  in  a  pan  of 
cold  water  with  folded  napkin  beneath  the  bottle  to  pre- 
vent unequal  heating.  Let  the  water  boil  for  three 
minutes.  Allow  to  remain  in  hot  water  for  eight  minutes. 
Cool. 

Pasteurized  Milk  (double  boiler). 

Place  milk  in  cold  water  bath,  having  water  to  level  of 
milk;  bring  milk  to  temperature  between  155°  and 
167°  F.  for  15  to  20  minutes. 

Sterilized  Milk  (double  boiler). 

The  milk  mixture  is  put  into  the  inner  vessel  cold,  and 
the  water  in  the  outer  vessel  is  also  cold.  The  double 
boiler  is  then  placed  on  the  stove  and  allowed  to  remain 
until  the  water  in  the  outer  vessel  boils  for  6  to  8  min- 
utes; the  whole  process  requires  10  to  15  minutes. 
While  the  milk  heated  in  this  manner  forms  a  much  finer 
and  softer  curd  than  that  of  raw  milk,  it  is  not  as  fine 
as  the  milk  boiled  directly  over  the  flame. 

28 


434  INFANT   FEEDING. 

Whey. 

Heat  1  quart  of  clean  raw  milk  to  104°  F.,  and  add  1 
level  teaspoonful  of  chymogen  or  fresh  essence  of  pep- 
sin (Fairchild's).  Allow  it  to  stand  for  one-half  hour, 
pour  off  the  free  whey,  pour  the  curd  into  a  straining 
cloth  for  one-half  hour,  and  collect  the  remainder  of  the 
whey. 

Chymogen  Milk. 

Boil  milk  for  five  minutes,  cool  to  104°  F.,  and  add  1  full 
teaspoonful  of  chymogen  to  each  quart  of  milk,  and  stir 
for  one-half  minute.  Let  it  come  to  a  clabber  by  allow- 
ing it  to  stand  for  15  minutes;  then  beat  it  well  until  the 
curd  is  finely  divided.  Do  not  heat  above  100°  F.,  when 
preparing  individual  bottles  for  feeding,  otherwise  curds 
will  clump,  and  will  not  pass  through  the  nipple. 

Indications  for  chymogen  milk:  (1)  Vomiting  in  in- 
fancy; (2)  indigestion  due  to  the  large  curd  formation. 

Buttermilk  in  the  Home. 

A  pure  culture  of  lactic  acid  bacilli  is  added  to  raw, 
pasteurized,  or  boiled  milk  in  an  earthenware  dish,  and 
allowed  to  stand  at  about  80°  F.  for  15  to  20  hours,  or 
until  the  casein  is  coagulated.  Stir  vigorously  in  a  churn, 
or  with  a  spoon  or  egg-beater  until  the  curd  is  very  small, 
and  then  push  the  contents  through  a  fine  wire  strainer 
with  a  spoon.  If  the  buttermilk  is  too  thick,  add  a  small 
amount  of  water.  When  the  buttermilk  is  once  made, 
a  small  portion  (about  4  ounces)  may  be  used  as  the  in- 
oculating agent  for  the  next  supply  to  be  made.  In  this 
way  the  original  culture  may  be  made  to  last  from  six 
to  eight  days.  The  quality  and  action  of  the  product 
made  will  vary  but  little.  Add  4  ounces  of  buttermilk  to 
1  quart  of  fresh  milk,  incubate,  and  follow  the  above 
outline.  Sometimes  the  milk  will  not  coagulate,  although 
it  may  smell  sour.  Stirring  with  a  spoon  will  often  pro- 


APPENDIX.  435 

duce  coagulation  in  a  few  minutes.  The  fat  present  will 
rise  to  the  top,  and  when  coagulated  appears  as  a  brown- 
ish-yellow scum,  which  may  be  removed  before  the  curd 
is  broken  up.  At  the  present  time  the  market  is  flooded 
with  tablets  for  the  preparation  of  buttermilk,  but  one 
must  hesitate  before  using  them  to  prepare  milk  for  a 
baby.  A  pure  culture  should  be  used,  or  one  recom- 
mended by  the  physician.  Whole  or  skim  milk  is  to  be 
used  as  indicated  in  each  individual  case. 

Startoline. 

Carefully  pasteurize  2  quarts  of  fresh  whole  milk  to  a 
temperature  of  180°  F.  for  one  hour,  or  boil  for  five 
minutes ;  cool  quickly  to  about  80°  F.,  and  add  1  ounce 
of  Hanson's  Lactic  Ferment  Culture,  and  let  it  stand  un- 
disturbed until  well  curdled,  which  should  be  in  15  or  20 
hours,  at  a  temperature  of  75°  F.  Then  place  on  ice. 
When  ready  to  use,  beat  curd  up  with  a  spoon  until  it  is 
of  a  creamy  consistency. 

Buttermilk  for  Hospital  Feeding. 

Pasteurize  whole  sweet  milk  to  a  temperature  of  180° 
F.  for  one  hour;  then  place  in  cold  water  until  cooled  to 
80°  F.  Add  1  ounce  of  startoline  to  every  quart  of  milk, 
stir  with  a  spoon,  and  cover;  allow  to  stand  from  15  to 
20  hours,  then  churn  for  one  hour ;  then  add  a  little  cold 
sterile  water  to  break  butter  away  from  milk ;  and  strain 
buttermilk. 

Buttermilk  and  Skim  Milk  Mixture. 

To  a  few  tablespoonfuls  of  buttermilk  or  skim  milk 
add  2%  level  tablespoonfuls  of  flour  (flour  ball  or  dex- 
trinized  barley  flour),  to  make  a  paste.  Make  up  to  1 
quart  with  buttermilk.  (1)  Bring  to  a  boil,  withdraw 
from  fire.  (2)  Bring  to  a  boil,  withdraw  from  fire  a 
second  time.  (3)  Add  4  level  tablespoonfuls  of  cane- 


436  INFANT   FEEDING. 

sugar,  and  bring  to  a  boil  for  the  third  time.  (Maltose- 
dextrin  preparations  are  best  in  all  diarrheal  conditions.) 
(1,  2,  and  3  should  require  about  twenty  minutes  time.) 
Make  up  to  1  quart  with  boiled  water,  if  it  has  boiled 
away;  put  on  ice.  It  is  well  to  start  with ~ one-half  the 
amount  of  sugar,  and  increase  as  indicated. 

Indications  for  buttermilk  and  skim  milk  mixtures: 

1.  Fat  indigestion. 

2.  Loose  bowels  (it  may  be  necessary  to  reduce  the 

amount  of  sugar.     The  high  protein  contents 
tend  to  constipate). 

3.  Malnutrition,   with   stationary  weight. 

Brady's  Mixture  No.  1. 

Dr.  Jules  Brady,  of  St.  Louis,  has  suggested  the  two 
mixtures  following,  which  contain  less  carbohydrates 
than  the  above  buttermilk  mixture,  and  which  he  has 
found  especially  valuable  in  the  feeding  of  infants  in 
institutional  practice. 

Mixture  No.  1,  which  is  used  for  young  infants  during 
the  first  two  months,  contains  1 1  calories  in  each  ounce ; 
the  young  infant  receives  4  ounces  of  this  mixture  for 
every  pound  of  body  weight  as  soon  as  it  will  take  it. 
The  baby  weighing  6  pounds  at  birth  is  allowed  to  take 
24  ounces  in  twenty-four  hours,  or  3.5  ounces  every  three 
hours,  7  feedings  in  twenty-four  hours.  The  average  in- 
fant at  three  or  four  days  will  take  1  ounce;  at  eight 
days,  1  to  2  ounces;  at  fourteen  days,  \l/2  to  2  ounces; 
at  three  weeks,  2  ounces ;  at  six  weeks,  3  ounces ;  at  eight 
weeks,  4  ounces. 
Mixture  No.  i. 

24  quart  buttermilk  or  skim  milk. 

l/4  quart  barley  water  (thick). 

1  ounce  by  measure,  Mellin's  Food. 

y2  ounce  granulated  sugar. 


APPENDIX.  437 

The  ingredients  are  mixed  together  in  the  following 
manner:  To  the  barley  gruel  is  added  the  cane-sugar 
and  the  Mellin's  Food,  and  then  the  milk  is  slowly  added, 
and  the  mixture  strained.  As  a  rule,  the  milk  is  acidi- 
fied with  lactic  acid  bacilli  twelve  hours  before  being 
made  up,  having  first  agitated  it. 

Brady's  Mixture  No.  2. 

On  reaching  a  weight  of  8^  to  9  pounds,  infants  re- 
ceive the  mixture  No.  2,  which  contains  18  calories  for 
every  ounce.  The  babies  are  allowed  3  ounces  of  the 
mixture  No.  2  for  every  pound  of  body  weight. 

Mixture  No.  2. 

%  quart  whole  fresh  milk  or  whole  buttermilk. 
Yz  quart  barley  water  (thick). 
1  ounce  granulated  sugar. 

Keller's  Malt  Soup. 

To  11  ounces  (330  Gm.)  of  warm  milk  gradually  add 
1%  ounces  (50  Gm.)  of  flour,  stir  constantly,  then  pour 
through  a  clean  sieve  or  muslin.  In  another  dish  dis- 
solve 3  ounces  (100  Gm.)  by  weight,  or  2^  ounces  or 
tablespoonfuls  by  measure,  of  Borcherdt's  malt  extract 
with  potassium  carbonate  in  20  ounces  (600  Gm.)  of 
boiled  warm  water.  Then  mix  both  solutions,  put  on 
fire,  stir  continuously,  and  boil  for  two  or  three  minutes. 

Indications  for  Keller's  Malt  Soup : 

1.  Fat  indigestion. 

2.  Disturbed  metabolic  balance  (fat-soap  stools). 

3.  Chronic  constipation    (often  relieved  by   simple 

addition  of  malt  soup  extract  to  ordinary  milk 
mixture  in  place  of  part  of  sugar). 

Contraindications: 

1.  Before  the  third  month,  if  the  stools  are  loose. 


438  INFANT   FEEDING. 

2.  For  a  period  of  more  than  four  to  eight  weeks 
(to  be  followed,  where  possible,  by  ordinary 
milk  mixtures,  the  strength  of  the  latter  being 
gradually  increased). 

Cream  Soups. 

Creajn  soups  may  be  made  from  vegetable  pulp,  using 
1  tablespoonful  of  cooked  potatoes,  peas,  or  asparagus  to 
Y-2.  cup  of  water  in  which  the  vegetables  were  cooked,  ^ 
cup  of  sweet  milk,  and  ^  teaspoonful  of  flour,  with  a 
little  butter  and  salt.  Cook  another  minute  or  two. 
Strain  if  necessary.  Serve. 

Corn  or  tomatoes  may  be  used  in  the  same  manner, 
using  2  tablespoonfuls  of  strained  vegetables,  with 
about  one-third  water  and  two-thirds  milk.  When 
tomatoes  are  used,  add  a  small  pinch  of  soda  to  tomatoes 
before  adding  other  ingredients. 

Vegetable  Soup. 

One-fourth  pound  lamb  stew,  cut  into  pieces,  1  potato 
cut  into  pieces,  1  carrot  cut  into  pieces,  2  stalks  of  celery 
cut  into  pieces,  1  tablespoonful  of  pearl  barley,  2  table- 
spoonfuls  rice,  2  quarts  water.  Boil  down  to  1  quart; 
boil  three  hours.  Add  pinch  of  salt,  and  strain  before 
feeding. 

Lamb,  or  Veal  Broth. 

Lean  meat  chopped  fine,  1  pound ;  cold  water,  1  quart ; 
a  pinch  of  salt ;  cook  slowly  two  or  three  hours  to  1  pint. 
Add  water  from  time  to  time,  so  that  when  finished  there 
will  be  1  pint  of  broth.  Strain ;  when  cold,  skim  off  fat. 

Chicken  Broth. 

Small  chicken,  or  one-half  of  large  fowl,  with  all  skin 
and  fat  removed ;  chop  bones  and  all  into  small  pieces ;  add 
1  quart  boiling  water  and  a  little  salt ;  cover  closely,  and 


APPENDIX.  439 

allow  to  simmer  over  a  slow  fire  for  two  hours.  After 
removing  allow  to  stand  one  hour;  then  strain.  Add 
water,  if  necessary,  from  time  to  time,  so  that  there  will 
be  1  pint  when  finished. 

Farina  Soup. 

To  1  pint  of  meat  broth,  gradually  add,  while  stirring, 
1  even  tablespoonful  of  farina,  and  boil  down  to  1  cup 
(l/2  pint)  in  about  twenty  minutes.  It  is  a  good  plan  to 
boil  the  farina  for  from  fifteen  to  twenty  minutes  before 
adding  it  to  the  broth ;  then  broth  and  farina  need  to  be 
boiled  together  for  but  ten  minutes. 

Dried  Fruit  Soup. 

Wash  thoroughly  1  cup  of  dried  apricots  and  1  cup  of 
prunes.  Cook  in  1  quart  of  cold  water  until  very  soft. 
Strain  and  pres&out  all  juice.  Sweeten  to  taste.  Thicken 
with  a  tablespoonful  of  rice  flour  to  1  quart  of  the  liquid. 
Cook  twenty  minutes  to  remove  the  raw  taste  of  the 
flour. 

Soy  Bean  and  Condensed  Milk  (Ruhrah). 

Add  a  level  tablespoonful  of  soy  bean  flour  to  2  level 
tablespoonfuls  of  barley  flour,  add  a  pinch  of  salt,  and 
mix  to  a  paste  with  boiled  water,  adding  further  water  to 
1  quart.  Boil  for  twenty  minutes,  and  add  water  to  make 
up  for  the  loss  due  to  evaporation  during  boiling,  so  that 
total  mixture  is  1  quart.  Condensed  milk  is  now  added, 
varying  in  quantity  from  l/2  to  1  dram  of  condensed 
milk  to  each  ounce  of  the  mixture,  depending  upon  the 
age  and  the  condition  of  the  infant.  Double  the  quantity 
of  soy  bean  and  barley  flours  may  be  used  for  older  chil- 
dren. Each  ounce  of  soy  bean  gruel  contains  10  grams  of 
protein  and  102  calories.  Two  ounces  of  soy  bean  gruel 
in  a  quart  of  water  contains  0.56  per  cent,  protein,  0.62 
per  cent,  fat,  and  3.31  per  cent,  sugar. 


440  INFANT   FEEDING. 

The  quantity  of  the  feedings  may  be  varied  according 
to  the  condition  and  nee"ds  of  the  infant,  varying  from  1 
to  8  ounces  per  feeding. 

It  is  indicated  whenever  fresh  clean  milk  is  not  ob- 
tainable, in  infants  with  marasmus,  in  some  intestinal 
disturbance  associated  with  diarrhea. 

Beef  Juice. 

Take  %  to  l/2  pound  round  steak,  broil  slightly,  cut 
into  small  pieces,  and  then  press  out  the  juice  with  a  meat 
press  or  potato  ricer,  and  add  a  small  pinch  of  salt.  Feed 
fresh,  or  warm  before  giving,  but  do  not  heat  sufficiently 
to  coagulate  albumin. 

Potatoes. 

Boil  potatoes  in  salt  water  in  the  ordinary  way  until 
they  are  thoroughly  done.  Then  mash  through  a  very 
fine  sieve,  and  add  a  little  butter. 

Spinach. 

Cook  spinach  in  salted  water  until  tender.  Pour  cold 
water  over  it,  and  drain.  Chop  fine,  or  rub  through  a 
coarse  sieve.  To  2  tablespoonfuls  of  spinach  add  1  tea- 
spoonful  of  fine  breadcrumbs,  l/2  teaspoonful  melted  but- 
ter, and  a  little  salt.  Reheat  and  serve. 

Asparagus. 

Cook  one-half  of  a  bunch  of  asparagus  in  about  a  pint 
of  slightly  salted  water.  When  tender,  remove  stalks  one 
by  one.  Place  on  a  warm  plate,  and  remove  pulp  by 
taking  hold  of  the  firm  end  of  the  stalk,  scraping  lightly 
with  a  fork  toward  the  tips.  Use  pulp  only.  Make  a 
sauce  with  one-fourth  of  a  cup  of  water  in  which 
asparagus  was  cooked,  one-fourth  of  a  cup  of  milk,  1 
teaspoonful  flour,  a  little  butter  and  salt.  Dip  a  small 
piece  of  toast  in  the  sauce.  Take  what  is  left  of  the 


APPENDIX.  441 

sauce  and  mix  with  2  tablespoonfuls  of  asparagus  pulp. 
Reheat.    Place  on  toast  and  serve. 

Carrots. 

Cook  y-z  pound  of  young  carrots  in  a  pint  of  fat-free 
soup  stock  or  slightly  salted  water,  adding  more  if  it 
cooks  away  before  they  are  done.  Rub  through  a  sieve ; 
add  1  teaspoonful  of  bread-crumbs,  a  little  butter  and 
salt.  Reheat  and  serve. 

Beans. 

Soak  2  ounces  or  4  tablespoonfuls  of  beans,  and  cook 
them  slowly  in  a  good  deal  of  water  until  they  are  soft, 
but  not  broken.  Rub  through  a  sieve,  add  1  cupful  of 
soup  stock,  and  let  them  cook  for  one-half  hour,  adding 
more  stock  if  it  boils  away.  Mix  a  little  butter  and  flour, 
about  a  teaspoonful  of  each,  and  a  little  salt.  Add  to 
soup.  Return  to  fire,  and  cook  for  a  few  minutes. 

Green  Peas. 

Cook  a  cupful  of  green  peas  in  boiling  salted  water 
until  they  are  done.  Drain,  saving  the  water  in  which 
they  are  cooked.  Rub  through  a  coarse  sieve.  Make  a 
sauce  of  2  tablespoonfuls  of  water  in  which  the  peas 
were  boiled,  2  tablespoonfuls  of  sweet  milk,  y2  teaspoon- 
ful flour,  y-2.  teaspoonful  fine  bread-crumbs.  Mix  all 
together.  Reheat  and  serve. 

Fruits. 

(a)  Orange  Juice:  Take  sweet  orange,  cut  into  halves, 
and  squeeze  out  juice  by  hand  or  with  a  lemon  squeezer; 
strain,  put  on  ice,  and  use  as  ordered. 

(&)  Prune  Juice:  Take  */2  pound  of  prunes,  wash 
thoroughly,  cover  with  cold  water,  and  soak  overnight. 
In  the  morning  place  on  stove  in  the  same  water,  and 


442  INFANT   FEEDING. 

cook  until  tender.     Add   1    teaspoonful  of   sugar,   and 
strain. 

(c)  Prune  Jelly:    Cover  1  pound  of  prunes  with  1 
quart  of  water;  cook  slowly  until  tender;  pit,  and  press 
pulp  through  a  sieve.     Add  sugar  to  sweeten   (2  tea- 
spoonfuls)  and  YZ  box  of  gelatin  dissolved  in  a  pint  of 
water,  and  boil.     Strain,  cool,  and  keep  covered. 

(d)  Apple  Sauce:   Take  6  apples  and  peel,  core,  and 
cut  them  into  quarters.    Place  them  in  an  enameled  dish ; 
sprinkle  over  them  1  tablespoonful  of  sugar;  add  1  cup 
of  cold  water;  put  the  dish  on  the  stove,  and  boil  the 
apples  to  a  mush  (about  thirty  minutes). 

(e)  Orange  Gelatin:   Soak  */£  box  of  shredded  gelatin 
in  cold  water  for  thirty  minutes.    Add  2  cupfuls  of  boil- 
ing water,  and  dissolve.     Then  add  1  cupful  of  sugar, 
the  juice  of   1    lemon,  and  a  cupful   of  orange  juice. 
Strain  through  a  fine  strainer  (or  a  cloth)  into  moulds, 
and  set  away  to  harden. 

Eggs. 

Use  only  soft-boiled  or  poached  eggs.  Be  sure  that 
the  eggs  are  fresh.  Drop  egg  in  boiling  water;  imme- 
diately turn  flame  out,  and  allow  to  stand  for  five 
minutes. 

Casein  Gruel. 

To  make  10  ounces — each  ounce  equals  18  calories: 
Casein,  6  level  tablespoonf uls ;  flour  ball,  2  level  table- 
spoonfuls;  water,  6  ounces;  milk,  8  ounces. 

Mix  casein  and  flour  ball  together  with  the  water — 
let  boil  three  minutes  directly  over  the  flame,  stirring 
constantly.  Add  the  milk  gradually  and  bring  again  to 
boil.  Place  in  double  boiler  and  cook  three  to  four  hours, 
stirring  occasionally.  Strain. 


APPENDIX.  443 

Thick  Cereal  (Sauer).i 

Skimmed  milk,  9  ounces;  water,  12  ounces;  farina, 
6  tablespoonf uls ;  Dextri-Maltose,  3  tablespoon fuls. 

Boil  for  one  hour  in  a  covered  double  boiler.  Sugar 
and  salt  may  be  added. 

Pap. 

Put  1  pint  of  milk  on  to  boil ;  add  butter  the  size  of  a 
walnut.  Beat  1  egg  thoroughly.  When  milk  boils,  add 
the  beaten  egg,  stirring  constantly.  Mix  ll/2  tablespoon- 
fuls  flour  into  a  paste  and  add  to  mixture,  stirring  con- 
stantly. Allow  mixture  to  boil  ten  minutes.  Just  before 
taking  from  the  fire  add  a  pinch  of  salt.  May  be  taken 
plain,  or  with  milk  and  sugar  as  directed. 

Cornstarch  Pudding. 

Take  1  pint  of  milk  and  mix  with  2  tablespoonfuls  of 
cornstarch;  cane-sugar,  1  tablespoon ful.  Flavor  to 
taste;  then  boil  the  whole  eight  minutes.  Allow  to  cool 
in  a  mould. 

Custard  Pudding. 

Break  1  egg  into  a  teacup  and  mix  thoroughly  with 
sugar  to  taste.  Then  add  milk  to  nearly  fill  the  cup. 
Mix  again,  and  tie  over  the  cup  a  small  piece  of  linen. 
Place  the  cup  in  a  shallow  saucepan  half  full  of  water, 
and  boil  for  ten  minutes. 

If  it  is  desired  to  make  a  light  batter  pudding,  a  tea- 
spoonful  of  flour  should  be  mixed  in  with  the  milk  be- 
fore tying  up  the  cup. 

Infant's  Gelatin  Food. 

About  1  teaspoonful  of  gelatin  should  be  dissolved  by 
boiling  in  l/2  pint  of  water.  Toward  the  end  of  the  boil- 

1  L.  W.  Sauer :  Thick  cereal  in  the  treatment  of  pyloric  steno- 
sis. Arch,  of  Fed.  xxxv,  385,  1918. 


444  INFANT   FEEDING. 


ing,  *4  P^t  of  cow's  milk  and  1  teaspoonful  of  arrow- 
root (made  into  a  paste  with  cold  water)  are  to  be 
stirred  into  the  solution,  and  1  to  2  tablespoonfuls  of 
cream  added,  just  at  the  termination  of  the  cooking.  It 
is  then  to  be  moderately  sweetened  with  white  sugar, 
when  it  is  ready  for  use.  The  whole  preparation  should 
occupy  about  fifteen  minutes. 

Albumin  or  Eiweiss  Milk  (Finkelstein). 

One  quart.  Take  fresh  whole  milk,  bring  to  a  tern-' 
perature  of  98°  to  100°  F.  Then  add  2  level  tablespoon- 
fuls of  chymogen  powder  to  a  quart  of  milk  ;  place  in  a 
water  bath  of  107°  F.,  for  fifteen  to  twenty  minutes, 
until  coagulated.  Then  hang  in  a  sterile  muslin  bag  for 
one  hour  to  drain. 

To  the  curd  of  1  quart  of  milk  add  1  pint  of  buttermilk, 
and  rub  through  a  copper  gauze  strainer  three  times. 
Then  add  2  level  tablespoonfuls  of  wheat  flour,  flour 
ball,  or  Imperial  Granum,  rubbed  to  a  paste  with  1  pint 
of  water.  Boil  ten  minutes,  cutting  back  and  forth  con- 
stantly, not  stirring,  with  a  large  wooden  spoon,  other- 
wise large  curds  will  form.  If  needed,  water  should 
again  be  added,  to  make  the  finished  mixture  one  quart. 
Finkelstein  advises  the  early  addition  of  3  per  cent,  of 
carbohydrate  in  the  form  of  a  maltose-dextrin  compound. 
This  is  best  done  by  dissolving  the  sugar  in  a  moderate 
quantity  of  water,  and  adding  while  the  mixture  is  being 
boiled.  It  must  not  be  heated  above  100°  F.  before  feed- 
ing, otherwise  it  will  clump. 

Albumin  milk  contains  :  protein,  3  per  cent.  ;  fat,  2.5 
per  cent.;  milk-sugar,  1.5  per  cent.;  starch,  1.0  per  cent.; 
salts,  0.5  per  cent.  Caloric  value  is  450  calories  per  liter, 
or  12  calories  per  ounce. 

Indications  for  albumin  milk  (Finkelstein)  : 

1.  Diarrheas  and  all  cases  of  abnormal  intestinal  fer- 
mentation (sugar). 


APPENDIX.  445 

2.  Fat  indigestion  with  low  sugar  tolerance. 

3.  Gastro-intestinal  infections  associated  with  fre- 

quent stools. 

4.  Systemic  infections  with  intestinal  complications. 

Albumin  Milk  (Miiller  and  Schloss). 

Use  1  quart  of  water  and  1  quart  of  buttermilk,  and 
boil  for  three  minutes.  Set  aside  for  thirty  minutes,  and 
then  pour  off  the  upper  36  ounces  of  the  whey.  Boil  the 
upper  4.5  ounces  of  a  quart  of  fresh  milk  for  three  min- 
utes. Add  1  ounce  of  dextri-maltose  to  the  boiled  top 


Fig.  28. — Utensils  needed  for  artificial  feeding:  Double 
boiler  (small),  pan,  funnel,  bottle-brush,  250-mil  (8  oz.) 
graduated  glass  or  pitcher,  6  nursing  bottles  and  rack, 
paper  caps  for  bottles  (sterile),  nipples,  milk,  sugar,  flour, 
milk  of  magnesia,  citrate  of  soda,  tablespoon,  dairy  ther- 
mometer, vegetable  mill. 

milk,  and  to  this  add  the  curds  from  the  first  mixture, 
which  would  equal  27.5  ounces,  making  1  quart  of  the 
milk  mixture. 

Larosan  Milk. 

Two-thirds  of  an  ounce  of  Larosan  powder  (p. 
428)  is  added  to  ^2  pint  of  milk,  and  mixed  thoroughly. 
Another  whole  pint  of  milk  is  heated  to  the  boiling  point. 
When  it  has  come  to  a  boil,  it  is  added  to  the  Larosan 
milk  mixture,  and  the  whole  is  placed  on  the  flame  and 
allowed  to  boil  for  five  minutes.  This  may  be  diluted 


446  INFANT  FEEDING. 

with  water  in  the  proportion  of  one-half  Larosan  milk 
and  one-half  water,  or  two-thirds  Larosan  milk  and  one- 
third  water. 

This  mixture,  because  of  its  high  protein  content  and 
comparative  ease  of  preparation,  can  be  used  as  a  substi- 
tute for  albumin  milk  in  the  home. 

Butter  and  Flour  Mixture  of  Czerny  and 
Kleinschmidt.1 

The  Butter-flour  feeding  which  is  recommended  by 
Czerny  and  Kleinschmidt  represents  a  utilization  of  the 
fat  of  the  cow's  milk.  It  is  claimed  that  the  mixture 
is  well  tolerated,  even  by  very  young  and  underweight 
infants. 

For  the  preparation  of  this  feeding,  for  every  100  Gm. 
of  the  diluting  fluid,  7  Gm.  of  butter,  7  Gm.  of  wheat 
flour  and  5  Gm.  of  cooking  sugar  are  used.  The  butter 
is  heated  above  a  small  flame,  with  good  agitation  with 
a  wooden  spoon  until  it  begins  to  foam  and  all  odor  of 
fatty  acids  has  disappeared.  Then  the  wheat  flour  is 
added  and  mixed  with  the  melted  butter.  Both  of  these 
are  then  cooked  over  a  moderate  fire  (asbestos  plate), 
with  constant  mixing  until  the  mass  becomes  thin  and 
somewhat  brownish.  Then  100  Gm.  of  warm  water  and 
5  Gm.  of  sugar  are  added  and  the  entire  mixture  is  again 
boiled,  strained  through  a  hair  sieve  and  finally  added  to 
the  boiled  and  afterwards  cooled  milk.  The  mixture 
ready  for  feeding  must  be  kept  cool,  but  it  is  not  neces- 
sary to  sterilize  it  again.  The  amount  to  be  added  to 
milk  mixtures  in  infants  below  3000  Gm.  should  be  one- 
third  ;  in  those  of  about  3000  Gm.  and  above,  about  two- 
fifths  of  the  final  mixture.  It  should  be  administered 
in  quantities  of  not  more  than  200  Gm.  per  kilo  body 
weight  in  a  day. 


Jahrbuch  f.  Kinderh.  87,  1918. 


APPENDIX.  447 

Meats. 

Raw  or  slightly  cooked  beef,  scraped  and  seasoned, 
can  be  fed  in  amounts  equaling  a  tablespoonful  at 
eighteen  months  or  sooner,  once  daily. 

Take  meat,  preferably  from  the  round,  free  from  fat. 
Place  on  a  board  and  scrape  with  a  silver  spoon.  When 
you  have  the  desired  amount  of  meat  pulp,  shape  into  a 
pat  and  broil  on  a  hot,  dry  spider.  Do  not  cook  too  long. 
When  done,  season  with  a  little  salt  and  butter.  Serve. 
A  few  drops  of  lemon  juice  may  be  added. 

Later,  lamb,  beefsteak,  roast  beef  and  chops  are  the 
best,  and  should  be  broiled.  By  no  means  fry  any  meat 
for  the  baby.  Soup  meat,  well  cooked,  may  also  be  given. 
All  meats  should  be  very  finely  cut  before  giving  them 
to  children. 

BOTTLES    AND    NIPPLES    AND    THEIR    CARE. 

The  nursing  bottle  should  be  of  such  a  construction 
that  every  portion  of  it  is  easily  reached  with  a  proper 
brush.  This  necessitates  the  avoidance  of  sharp  corners 
and  angles,  and  makes  the  smooth  stream  lines  in  its 
construction  desirable.  It  should  be  made  of  good  glass, 
not  easily  broken,  capable  of  being  boiled  repeatedly 
without  cracking,  and  should  hold  about  8  to  10  ounces. 
Several  nursing  bottles  should  be  kept  on  hand,  and,  if 
possible,  as  many  bottles  as  there  are  nursings  in  a  day 
should  be  available,  so  that  the  whole  day's  feeding  may 
be  prepared  according  to  the  particular  formula,  and  the 
mixture  then  iced,  and  the  individual  bottles  warmed  on 
a  water-bath  whenever  necessary.  New  bottles  should 
be  annealed  by  placing  them  in  a  vessel  with  cold  water, 
and  then  bringing  the  water  to  a  boil,  boiling  for  twenty 
minutes,  and  then  leaving  the  bottles  in  this  water  until 
it  will  cool  off  again.  Bottles  thus  treated  do  not  crack 
so  easily  when  hot  fluids  are  poured  into  them.  After 
nursing,  the  bottle  should  immediately  be  rinsed  with 


448  INFANT  FEEDING. 

cool  water,  and  then  washed  with  hot  water  and  soap 
suds  by  means  of  a  bottle  brush.  Afterwards  the  bottle 
should  be  set  aside,  inverted,  so  as  to  drain.  Before  use, 
the  bottles  should  be  boiled  for  five  minutes.  To  avoid 
cracking,  they  must  be  placed  in  cold  water  and  heated 
slowly.  After  the  food  has  been  prepared,  the  individual 
bottles  may  be  filled  and  stoppered  with  sterile  cotton,  or, 
better,  sterile  paper  caps,  which  are  sold  for  this  purpose. 


Fig.  29. — Good  and  bad  nursing  bottles.  1.  Ordinary 
small-neck  nursing  bottle  as  sold  in  drug  stores  (8-ounce). 
2.  Improved  large-neck  nursing  bottle  (made  in  5-  and  10- 
ounce  size).  3.  Hygiea  nursing  bottle. 

Nipples  that  can  be  turned  inside  out  and  easily 
cleansed  should  be  selected.  The  conical  shaped  nipple  is 
preferable.  The  hole  in  the  nipple  should  be  of  such  size 
that  the  milk  will  drop  rapidly  and  not  flow  when  the 
bottle  is  inverted.  New  nipples  should  be  boiled  before 
they  are  used.  After  using,  every  nipple  should  imme- 
diately be  washed  with  soap  and  water,  being  turned  in- 
side out,  boiled  and  finally  dropped  into  a  sterile  jar, 


APPENDIX.  449 

• 

where  it  is  to  be  kept  dry  until  ready  for  use  again. 
Keeping  the  nipples  dry  lengthens  the  life  of  the  rubber. 
Several  nipples  should  always  be  kept  on  hand. 

CARE    OF   FOOD    DURING   TRAVELING. 

Whenever  possible,  the  baby  should  be  kept  on  its 
usual  diet  during  the  long  journey.    This  is  usually  ac- 


Fig.  30. — A  milk  station  consisting  of  three  rooms.  Room 
1.  For  all  used  bottles,  bottle  washers,  and  steam  bottle 
sterilizers.  Room  2.  A  clean  room  for  preparation  of  for- 
mulae. This  room  also  contains  milk  separator,  fat-test- 
ing apparatus  and  butter  churn.  Room  3.  Pasteurizing  and 
sterilizing  apparatus. 

complished  without  much  difficulty  when  the  baby  is  on 
boiled  milk.  If  it  has  been  fed  on  a  raw  milk  mixture, 
the  milk  must  be  boiled  before  starting.  When  for  any 
reason  it  is  impractical  to  carry  the  milk  mixture,  evap- 
orated milk  or  powdered  milk  may  be  used.  (See  Pro- 
prietary Infant  Foods,  page  425.)  In  the  use  of  evapor- 

29 


450  INFANT   FEEDING. 

ated  milk,  a  fresh  can  must  be  opened  at  least  once  daily. 
When  it  is  known  that  the  baby's  formula  is  to  be 
changed,  it  should  be  tried  out  on  the  new  food  before 
starting  on  the  journey.  As  soon  as  possible,  the  pre- 
vious diet  should  be  re-established.  All  water  given  to  the 
baby  while  traveling  must  be  boiled.  The  infant's  food, 
after  boiling  for  at  least  ten  minutes,  should  either  be 
placed  in  individual  nursing  bottles,  or  in  bottles  holding 
not  more  than  1  pint,  so  that  not  more  than  two  or  three 
feedings  should  be  given  from  a  single  bottle.  The 
bottle  should  be  packed  in  ice,  using  care  so  that  none  of 
the  ice  reaches  the  top  of'  the  bottle.  Upon  reaching  the 
train  they  should  be  placed  in  the  ice-box  of  the  dining 
or  buffet  car,  unless  a  private  ice-box  is  available.  The 
baby's  bottle  can  be  warmed  on  the  train  by  setting  in  a 
dipper  of  warm  water,  which  may  be  carried  hot  in  a 
thermos  bottle,  if  the  journey  is  to  be  a  short  one.  Care 
must  be  taken  that  the  water  be  not  too  hot,  otherwise  the 
cold  bottles  will  be  cracked.  The  nipples  may  be  carried 
in  a  wide-mouthed,  well-corked  bottle,  sufficient  to  cover 
the  individual  feedings.  The  nipples  and  bottles  should 
be  cleansed  immediately  after  use. 

THE    DIAPER. 

The  diaper  should  be  made  of  soft,  light,  and  ab- 
sorbent material,  such  as  cotton  diaper  cloth,  which  can 
be  purchased  for  this  purpose.  Cotton-flannel  is  too  little 
absorbent,  and  soon  becomes  hard  as  a  result  of  washing. 
A  second  diaper  may  be  folded  into  a  square,  and  be 
laid  under  the  hips  to  prevent  the  moisture  from  reach- 
ing the  clothes,  or  instead  of  this  arrangement,  which  is 
rather  heating  and  bulky  for  summer  use,  a  small  diaper 
may  be  folded  two  or  three  times  to  form  a  square  of 
about  nine  inches,  and  this  may  be  placed  inside  of  the 
larger  diaper  to  receive  the  urine  and  feces.  About  four 
dozen  diapers  are  needed  for  an  average  baby. 


APPENDIX.  451 

A  rubber  or  waterproof  cover  should  never  be  applied 
outside  the  diaper.  It  is  very  heating,  and  liable  to  pro- 
duce chafing  and  eczema.  Diapers  should  be  changed  as 
soon  as  soiled,  except  at  night,  when  they  should  be 
changed  when  the  child  is  awakened  for  feeding,  or 
when  it  is  awakened  by  its  own  discomfort.  Soiled 
diapers  are  always  a  source  of  discomfort,  and  not  infre- 
quently the  cause  of  severe,  irritation  of  the  skin,  as  well 
as  of  infections  of  the  genital  and  urinary  tracts.  This 
is  especially  true  in  the  case  of  female  infants.  No  diaper 
should  be  applied  a  second  time  without  first  being 
washed.  All  diapers  which  have  been  soiled  by  dis- 
charges from  the  bowel  should  have  the  bulk  of  the  feces 
removed  from  the  diaper,  and  should  be  immediately 
washed  with  soap  not  too  alkaline  in  character,  and  later 
boiled  for  twenty  minutes,  and  thoroughly  rinsed,  so  that 
all  alkali  may  be  removed.  They  should  then  be  aired 
thoroughly.  Soda  and  washing-powders  should  be 
avoided  because  of  the  danger  of  irritating  the  child's 
buttocks  after  being  moistened  by  the  urine. 

The  diapers  of  an  infant  ill  with  an  intestinal  infection 
should  be  cared  for  separately  from  those -of  other  chil- 
dren. After  changing  the  diapers,  the  nurse's  hands  and 
nails  should  be  scrupulously  cleansed  with  brush  and  file. 

BABY'S    DAILY    BATH. 

The  baby  should  be  bathed  at  least  once  a  day,  and  on 
hot  days  even  as  many  as  three  sponge-baths  may  be 
given.  In  the  first  six  months  the  temperature  of  the 
bath  should  be  100°  F.,  and  in  the  second  half  of  the 
year  from  90°  to  95°  F.  The  room  in  which  the  bathing 
is  done  should  have  a  temperature  of  at  least  70°,  and 
not  more  than  75°  F. 

Toward  the  end  of  the  first  year  the  infant  may  be 
sprayed  for  15  to  30  seconds  with  water  at  75°  to  80°  F. 
This  should  be  followed  by  brisk  rubbing  of  the  entire 


452 


INFANT  FEEDING. 


body.  In  young  infants  the  bath  is  most  conveniently 
given  before  the  mid-morning  feeding,  and  the  face  and 
hands  may  be  sponged  before  the  6  o'clock  feeding.  In 
older  infants,  a  cool  sponge  and  massage  may  be  given  in 
the  morning,  and  the  warm  bath  at  bedtime. 

Before  the  umbilical  cord  has  separated,  sponge-bath 
only  should  be  given,  and  never  a  submersion  bath,  for 


Fig.  31. — Hospital  bathroom.  Located  between  two  small 
wards  for  infants,  showing  two  metal  water  jackets  rest- 
ing on  a  porcelain  sink.  These  can  be  filled  with  water,  and 
have  a  registering  thermometer  for  indicating  the  tempera- 
ture before  giving  the  bath.  They  are  covered  with  a  clean 
towel  for  each  baby.  Baby  is  showered  from  an  automatic 
mixing  tank,  which  registers  temperature  of  the  water  in 
the  tank.  The  room  further  contains  a  scale  and  a  low 
dressing  table,  with  the  various  dressings,  powders  and 
ointments  to  be  used.  Also  low  nursery  chairs,  collapsible 
bags  for  soiled  linen,  and  waste  basins. 

the  fear  of  infection  of  the  umbilical  stump.     Sponge- 
bath  may  be  given  on  a  towel,  and  when  a  tub-bath  is 


APPENDIX.  453 

given,  the  child  should  be  allowed  to  rest  upon  the  at- 
tendant's left  arm,  which  is  slipped  under  its  back  from 
the  baby's  right  side.  By  grasping  the  baby  under  the 
armpit  with  the  left  hand  a  good  hold  is  secured,  which 
prevents  slipping.  The  right  hand  is  left  free  for  wash- 
ing the  baby.  A  special  wash-cloth,  preferably  of  cheese- 
cloth, should  be  provided  for  washing  the  baby's  face  and 
head. 

A  pure,  bland,  white  soap  should  be  used.  Very  little 
soap  is  needed  for  cleansing  the  baby's  skin,  and  it  is 
most  important  that  the  skin  should  be  thoroughly  rinsed. 
If  the  skin  is  sensitive  and  easily  irritated,  soap  should  be 
avoided,  and  the  bran-bath  (made  by  putting  a  handful 
of  bran  in  cheese-cloth  bag  and  soaking  this  in  the  water 
until  milky)  should  be  used. 

After  the  bath  the  baby  should  be  wrapped  in  a  large 
soft  towel  and  dried  by  sponging,  and  not  by  rubbing. 
Special  attention  should  be  paid  to  folds  and  creases  of 
the  skin,  and  these  should  be  well  powdered  after  being 
thoroughly  dried. 

Only  warm  baths  should  be  used  in  infants  who  be- 
come pale  and  cyanotic  when  a  cooler  bath  is  used. 

Care  should  be  taken  in  bathing  all  children  suffering 
from  coughs.  '  Great  care  should  also  be  used  while  bath- 
ing a  child  suffering  from  vulvovaginitis,  to  avoid  infec- 
tion of  the  eyes. 

COLD  BATH  AND  COLD  PACK. 

Cold  bath  is  an  efficient  antipyretic  and  nervous  de- 
pressant in  cerebral  irritation,  but  it  is  a  somewhat  severe 
procedure  for  the  infant,  and  is  less  frequently  indicated 
than  in  the  adult.  It  is  to  be  used  only  in  infants  who 
react  well.  The  bath  is  started  with  water  at  100°  F., 
and  the  temperature  is  then  gradually  lowered  by  the 
addition  of  ice-water,  down  to  about  80°  F.  The  infant 
should  be  continually  rubbed  while  in  the  bath.  The 


454  INFANT   FEEDING. 

bath  should  not  be  longer  than  five  to  ten  minutes,  and 
should  be  discontinued  at  once,  if  any  cyanosis  appears. 
The  infant  must  be  dried  quickly,  and  then  wrapped  in  a 
dry  blanket,  without  dressing,  and  put  to  bed. 

In  most  cases,  however,  a  cold  pack-  is  preferable  to 
cold  bath,  especially  in  young  infants,  as  the  former  is  a 
somewhat  milder  procedure.  Cold  pack  is  one  of  the  best 
antipyretic  procedures  in  infancy  and  childhood.  The 
naked  child  is  wrapped  in  a  blanket  wrung  out  of  water 
at  a  temperature  of  about  100°  F.,  and  is  then  rubbed 
with  ice  through  the  blanket  for  about  five  to  ten  min- 
utes. Ice-bag  to  head  and  hot-water-bag  to  feet  are  very 
useful — often  necessary.  After  rubbing  with  ice,  the 
child  .is  left  in  the  blanket,  and  covered  well.  The  blanket 
may  be  removed,  the  child  dried;  and  put  into  a  dry 
blanket  after  about  one  hour. 

HOT   BATH. 

Hot  bath  is  indicated  in  cases  of  collapse  or  shock  as  a 
stimulating  procedure;  and  prolonged  hot  bath  as  a  dia- 
phoretic procedure:  It  should,  be  started  with  water  at 
a  temperature  of  100°  F.,  and  the  temperature  gradually 
raised  to  about  105°  F.  by  addition  of  hot  water.  An 
ice-cap  or  cold  cloth  should  be  applied  to  the  head.  A 
thermometer  should  always  be  used  while  giving  a  hot 
bath.  The  infant  should  be  well  rubbed  during  the  bath, 
which  should  be  continued  for  about  ten  minutes.  After 
the  hot  bath  the  infant  should  be  well  dried,  until  the 
skin  is  red,  and  then  wrapped  in  a  blanket  and  put  to  bed. 

MUSTARD  BATH  AND  MUSTARD  PACK. 

Mustard  bath  and  mustard  pack  are  indicated  for  their 
stimulating  effect  in  cases  of  shock,  or  collapse,  and  in 
acute  congestion  of  internal  organs,  and  also  in  con- 
vulsions. 

The  amount  of  mustard  used  and  the  temperature  of 
water  is  the  same  in  both  procedures.  Powdered  mus- 


APPENDIX.  455 

tard,  in  quantity  of  about  1  level  tablespoonful  to  each 
gallon,  or  1  teaspoonful  to  each  quart,  when  smaller 
quantities  are  sufficient,  should  be  used.  Full  quantity 
of  mustard  powder  is  first  dissolved  in  about  a  gallon  of 
warm  water,  and  to  this  the  rest  of  the  water  is  added, 
while  preparing  the  bath.  For  giving' the  pack,  a  smaller 
quantity  of  water  is  usually  required.  The.  temperature 
of  the  water  should  be  about  100°  F.,  and  it  may  be 
raised  to  about  105°  F.  by  addition  of .  hot' water.  Cold 
applications  should  be  made  to  the  head. 

The  bath  should  be  continued  for  -about  ten  minutes, 
accompanied  by  rubbing  the  skin,  and  followed  by  ablu- 
tion with  lukewarm  water,  rapid  drying,  wrapping  in  a 
blanket,  and  rest. 

Mustard  pack  is  somewhat  less  efficient  than  mustard 
bath,  but  it  is  also  less  severe  and  less  disturbing  to  the 
infant.  The  naked  child  is  wrapped  in  a  blanket  which 
has  been  wrung  out  of  water  prepared  as  above  stated. 
The  infant  is  left  in  the  pack  until  the  skin  is  well  red- 
dened— about  ten  to  twenty  minutes — then  washed  off 
with  warm  water,  followed  by  lukewarm  water  ablution, 
dried,  and  put  to  bed  with6ut  dressing. 

STOMACH  WASHING. 

The  apparatus  for  stomach  washing  consists  of  a  soft 
rubber  catheter,  20  to  24  French,  or  infant  stomach-tube, 
a  small  funnel,  -attached  to  a  rubber  tube,  and  a  glass 
connection  between  the  catheter  and  the  tube. 

The  infant  is  wrapped  with  the  arms  confined,  and  is 
held  in  the  sitting  position,  with  a  large  basin  at  the 
nurse's  feet.  The  tongue  is  depressed  with  the  forefinger 
of  the  left  hand,  and  the  right  hand  passes  a  catheter 
rapidly  backwards  into  the  pharynx  and  down  into  the 
esophagus.  Gagging  is  aggravated  by  passing  this 
catheter  slowly.  After  the  catheter  is  part  way  in  the 
esophagus,  it  should  be  passed  more  slowly.  As  the 


456  INFANT   FEEDING. 

cardiac  orifice  is  passed,  and  the  catheter  enters  the  stom- 
ach, gagging  again  becomes  more  evident.  This  can  be 
used  as  a  sign  that  the  catheter  is  entering  the  stomach. 
A  good  rule  to  follow  in  passage  of  the  catheter  is  to 
measure  the  distance  from  the  root  of  the  nose  to  the 
tip  of  the  ensiform  cartilage,  which  approximates  the 
distance  from  the  teeth  to  the  cardiac  end  of  the  stom- 
ach, and  then  pass  the  catheter  about  an  inch  farther. 
The  passage  into  the  stomach  is  usually  marked  by  the 
appearance  of  curdled  milk  in  the  glass  connecting  tube. 
The  funnel  should  now  be  raised  as  high  as  possible,  to 
facilitate  the  escape  of  any  gases  from  the  stomach,  and 
should  then  be  lowered,  in  order  to  siphon  any  fluid  con- 
tents. The  funnel  is  then  raised,  and  warm  water  at  a 
temperature  of  about  100°  F.  is  poured  into  the  stomach 
quickly.  The  amount  of  water  passed  into  the  stomach 
at  any  time  should  about  equal  the  quantity  of  the  feed- 
ing to  which  the  child  is  accustomed.  The  funnel  is  then 
lowered,  just  before  all  of  the  water  leaves  the  tube,  and 
the  water  siphoned  out.  This  procedure  is  repeated  a 
number  of  times,  until  the  fluid  comes  back  clear.  Dur- 
ing withdrawal,  the  tube  must  be  compressed  carefully  to 
prevent  leakage  into  the  larynx.  The  washings  should 
be  collected  and  measured,  so  that  the  quantity  remaining 
in  the  stomach  may  be  estimated. 

Sterile  water  or  one-half  strength  normal  saline, 
Ringer's  solution,  or  a  solution  containing  sodium  chlo- 
ride 5  Gm.,  sodium  bicarbonate  5  Gm,,  and  water  100 
mils,  may  be  used.  It  is  frequently  advisable  to  allow 
part  of  the  solution  to  remain  in  the  stomach. 

Stomach  washing  is  indicated  in  vomiting  due  to  pylo- 
rospasm,  hypertrophic  pyloric  stenosis,  all  forms  of  gas- 
tric irritation,  chronic  indigestion,  acute  dilatation  of  the 
stomach,  and  food  and  drug  poisoning. 


APPENDIX.  457 

CATHETER   FEEDING   BY    MOUTH. 

The  same  apparatus  is  used  as  in  stomach  washing, 
the  same  technic  being  used  for  the  introduction  of  the 
catheter,  except  that  its  tip  should  not  be  made  to  pass 
the  cardiac  end  of  the  stomach,  the  food  being  allowed 
to  enter  the  esophagus  just  above  the  cardia.  This  is 
accomplished  by  passing  the  catheter  about  one-half  inch 
less  than  the  distance  from  the  root  of  the  nose  to  the 
tip  of  the  ensiform  cartilage.  The  infant  should  be  lying 
on  its  back,  and  not  in  sitting  posture,  as  recommended 
in  stomach  washing.  When  the  feeding  is  finished,  the 
catheter  should  be  tightly  pinched  between  fingers  and 
rapidly  withdrawn,  to  prevent  any  food  from  trickling 
into  the  larynx.  It  is  often  advisable  to  wash  the  stom- 
ach before  the  food  is  introduced.  (See  Fig.  7,  page 
89.) 

Catheter  feeding  is  indicated  in  the  feeding  of  pre- 
mature infants,  infants  refusing  their  diet,  those  too 
weak  to  nurse,  in  the  presence  of  persistent  vomiting,  and 
in  all  cases  of  delirium  and  coma. 

CATHETER   FEEDING    BY    NOSE. 

This  is  not  indicated  in  young  infants.  In  older  chil- 
dren it  is  often  impossible  to  pass  the  catheter  through 
the  mouth,  without  undue  struggling.  It  is  also  indicated 
in  throat  paralysis  following  poliomyelitis  and  diphtheria, 
and  after  throat  operations  and  intubation.  The  method 
is  similar  to  that  described  in  catheter  feeding  by  mouth, 
except  that  a  smaller  catheter  (No.  15  French)  is  to 
be  used. 

IRRIGATION  OF  THE  COLON  AND 
RECTAL  FEEDING. 

The  apparatus  varies  somewhat  with  the  purpose  to  be 
accomplished.  Where  large  quantities  of  fluids  are  to 
be  introduced,  it  is  necessary  to  use  a  douche-can  or 


458  INFANT   FEEDING. 

fountain  syringe,  4  to  5  feet  of  tubing,  and  a  flexible 
rectal  tube  or  soft  rubber  catheter  (size  20  to  24  French). 
When  small  quantities  are  to  be  introduced,  a  glass  fun- 
nel may  be  used  in  place  of  the  douche-can.  When  large 
quantities  of  fluid  are  used,  the  can  must  not  be  raised 
more  than  2  feet  above  the  child's  body.  The  child 
should  be  turned  upon  its  side,  with  the  lower  limb  ex- 
tended, and  the  upper  thigh  flexed  upon  the  abdomen. 
The  catheter  should  be  well  oiled,  and  introduced  for 
about  3  to  4  inches  when  large  quantities  are  to  be  given, 
and  further  introduction  of  the  catheter  may  be  made 
while  the  solution  is  flowing  into  the  rectum.  For  most 
purposes  the  solution  should  be  about  100°  F. 

Indications.  1.  To  produce  evacuation  of  the  bowel. 
A  salt  solution  containing  a  level  teaspoonful  of  salt  to 
a  pint  of  tepid  water  or  weak  soap-suds  solution,  or  a 
teaspoonful  of  glycerin  in  an  ounce  of  water;  or  in  the 
presence  of  large  fecal  masses,  2  or  3  ounces  of  sweet 
oil  may  be  used. 

2.  To  reduce  temperature.    At  least  1  to  4  quarts  of  a 
salt  solution  or  weak  soap-suds  enema  at  about  95°  F. 
should  be  used,  allowing  about  ^2  to  1  pint  to  enter  the 
rectum,  and  repeating  after  expulsion. 

3.  Rectal  feeding.    A  normal  salt  solution  or  nutrient 
enemata  containing  2  level  tablespoonfuls  of  dextrose  to 
the  pint  of  normal  saline  solution  may  be  used.     It  is 
indicated  in  cases  of  acidosis,  and  also  in  the  presence  of 
vomiting,  intoxication,  and  decomposition  where  the  body 
is  in  need  of  water.     It  is  usually  necessary  that  only  a 
small  amount  (2  to  6  oz.)  of  this  solution  be  introduced 
at  a  time,  or  that  it  be  given  by  the  drop  method.    Other- 
wise it  will  not  be  retained.     It  should  be  repeated  at 
regular  intervals  of  from  two  to  four  hours.    It  may  be 
necessary  to  compress  the  buttocks  for  twenty  minutes 
after  administration,  when  the  fluid  is  not  well  retained 
otherwise. 


APPENDIX.  459 

4.  Medication.  There  are  two  indications  for  rectal 
medication:  (1)  For  the  systemic  effect.  The  drugs 
most  commonly  used  for  this  purpose  are  chloral  hydrate 
and  the  bromides,  more  especially  in  the  presence  of 
convulsions  or  coma.  They  should  be  diluted  in  small 
quantities  of  water  or  salt  solution,  not  over  1  ounce,  and 
may  be  administered  in  about  four  times  the  oral  dose 
for  the  given  age.  (2)  For  local  effect.  Enemata 
are  indicated  for  their  local  effect  in  the  presence  of 
marked  tenesmus,  inflammation,  ulceration  and  hemor- 
rhage. Not  infrequently  the  tincture  of  opium  (3  to  5 
drops)  and  tincture  of  belladonna  (3  to  5  drops)  are 
administered,  probably  best  in  a  10  per  cent,  starch  solu- 
tion, for  their  sedative  effect.  In  the  presence  of  in- 
flammatory processes,  1  per  cent,  silver  nitrate  solution 
may  be  used. 

SALINE   SOLUTIONS. 

Solutions  administered  subcutaneously  and  intraven- 
ously should  be  maintained  at  a  temperature  approxi- 
mating 100°F. 

1.  For  subcutaneous  use.  They  are  especially  indi- 
cated in  the  presence  of  considerable  loss  of  body  fluids 
through  vomiting,  refusal  of  diet,  and  diarrhea,  and  in 
the  presence  of  acidosis.  Rectal  administration  should 
first  be  tried,  and,  in  case  that  sufficient  fluids  cannot  be 
administered  to  meet  the  infant's  needs  in  this  way,  hypo- 
dermoclysis  should  be  instituted.  In  infants  2  to  4 
ounces  can  usually  be  administered,  and  in  older  children 
4  to  6  ounces.  This  can  be  repeated  every  four  hours, 
if  necessary,  or  until  fluids  can  be  supplied  by  another 
route.  Fluids  can  be  administered  beneath  the  skin  of 
the  abdomen,  chest,  or  lumbar  region.  There  is  some 
shock  accompanying  the  administration  of  large  quanti- 
ties of  fluids  subcutaneously,  probably  due  to  the  pain, 
and  it  is  frequently  necessary  to  give  a  child  in  collapse 
some  subcutaneous  stimulation  of  camphor  in  oil  (10  per 


460  INFANT  FEEDING. 

cent.  1  mil),  or  adrenalin  solution  (1:1000,  about  5 
drops),  before  administration.  The  stimulating  injection 
is  to  be  made  in  regions  of  the  body  other  than  where  the 
saline  injection  is  made. 

The  best  solutions  for  this  purpose  are 

(a)  NaCl    7.5  grams. 

KC1    0.1 

CaCl    0.2       " 

Water,   q.  s.  ad  1000.0  mils. 

(b)  Dextrose  may  be  added  to  the  above  solution  in 

proportion  of  50  grams  to  the  liter  (5  per  cent.). 

All  solutions  used  for  subcutaneous  administration 
should,  if  possible,  be  made  from  fresh  distilled  water, 
and  re-sterilized  shortly  before  use. 

2.  Intravenous  injections.  The  same  solutions  as  in- 
dicated for  subcutaneous  use  may  be  administered  intra- 
venously. Sodium  bicarbonate,  30  Gm.  to  the  liter,  being 
added  in  the  presence  of  acidosis  and  dextrose,  50  Gm. 
to  the  liter  in  cases  of  malnutrition  and  decomposition. 
Either  direct  or  indirect  transfusions  of  blood  are  also 
of  extreme  value  in  the  presence  of  marked  marasmus. 

Technic.  In  older  infants  and  children  the  injection 
may  be  made  into  the  external  jugular  or  median  basilic 
or  median  cephalic  veins.  In  young  infants  with  open 
fontanelle,  the  longitudinal  sinus  is  the  most  convenient 
point  for  administration.  However,  in  the  use  of  the 
latter  method  extreme  care  must  be  used,  because  of  the 
ease  with  which  the  sinus  wall  can  be  punctured.  All 
apparatus  used  in  the  intravenous  administration  must 
be  thoroughly  and  freshly  sterilized  before  use.  Where 
a  moderate  quantity  of  fluid  is  to  be  administered  (2  mils, 
10  mils,  or  20  mils)  all-glass  Record  or  Luer  syringes  can 
be  used.  In  injection  of  fluids  into  the  longitudinal  sinus 
a  short  bevelled  needle,  about  0.75  inch  in  length,  should 
be  introduced  at  the  posterior  angle  of  the  fontanelle. 

The  region  of  the  fontanelle  is  sterilized,  and  the  first 
syringe  is  three-quarters  filled  with  the  fluid  to  be  in- 


APPENDIX.  46! 

jected.  The  syringe  is  now  connected  with  a  needle  by 
means  of  a  short  piece  of  rubber  tubing  to  allow  flexibil- 
ity in  case  of  movements  on  the  part  of  the  child,  and  the 
needle  is  passed  into  the  sinus,  its  entrance  being  recog- 
nized by  a  sudden  lessening  of  the  resistance.  Helmholz1 
suggests  that  the  question  of  negative  pressure  within  the 
sinus  is  one  that  must  not  be  overlooked,  and  it  is  always 
well  in  entering  the  sinus  to  have  the  syringe  attached, 
and  before  injection  to  withdraw  blood,  to  make  sure  that 
the  needle  is  in  the  sinus.  Unless  a  head-clamp,  as 
described  by  Helmholz  is  available,  two  assistants  are 
required,  one  to  hold  the  child's  head  firmly,  and  the 
second  to  manage  the  syringe,  while  the  physician  steadies 
the  needle.  From  100  to  200  mils  of  either  a  saline,  dex- 
trose solution  or  citrated  or  fresh  blood  can  usually  be 
administered  without  difficulty.  Unger2  has  described  an 
apparatus  whereby  large  quantities  of  fresh  blood  can  be 
transfused. 

HOME-MADE  ICE-BOX. 

The  following  home-made  ice-box  described  by  A.  F. 
Hess  will  answer,  if  a  more  elaborate  refrigerator  is 
not  available. 

Get  from  your  grocer  a  deep  box  about  18  inches 
square,  and  put  3  inches  of  sawdust  in  the  bottom.  Place 
two  pails  in  this  box — one  a  smaller  pail,  inside  the  other 
— and  fill  the  space  between  the  outer  pail  and  the  box 
with  sawdust.  The  nursing  bottles  filled  with  milk  are 
placed  in  the  inner  pail.  This  pail  is  then  filled  with 
cracked  ice,  which  surrounds  'the  bottles.  The  inner  pail 
should  have  a  tin  cover.  Nail  several  thicknesses  of 


1  Helmholz,    H.    F. :  The    longitudinal    sinus    as    the   place    of 
preference  in  infancy  for  intravenous  aspirations  and  injections, 
including  transfusion.     Am.  Jour.  Dis.  Child.,  x,  194,  1915. 

2  Unger,  J.  J. :  A  new  method  of  syringe  transfusion.     Jour. 
Am.  Med.  Ass'n.,  Ixiv,  582,  1915. 


462 


INFANT  FEEDING. 


newspaper  on  the  under  surface  of  the  cover  of  the  box. 
This  ice-box  should  be  kept  covered,  and  in  a  shady,  cool 
place.  The  water  from  melted  ice  should  be  poured  off. 
and  the  ice  renewed  at  least  once  each  day. 


Fig.  32. — Bed  complete,  with  removable  metal  lid  and 
collapsible  hood  in  place.  The  hood  and  lid  can  be  re- 
moved as  indicated. 

ELECTRIC-HEATED   WATER-JACKETED 
INFANT   BED. 

This  special  bed,  designed  by  the  author  is  for  use  in 
the  care  of  premature  and  poorly  nourished  infants.  The 
advantages  of  this  apparatus  are : 

1.  Safety.  The  maximum  temperature  to  which  the 
water  can  be  warmed  with  the  electric  heater  is  about 


APPENDIX. 


463 


155°  F.,  with  a  room  temperature  of  70°  F.  and  rheostat 
on  contact  6,  this  giving  a  maximum  temperature  within 
the  bed  of  about  1 10°  F.,  with  the  lid  and  hood  on. 

2.  Economy  of   operation,  and,  most  important,  the 
elimination  of  a  trained  attendant. 


Fig.  33.— 4,  copper  wall  covering  asbestos  layer ;  9,  stand 
supporting  bed;  11,  14,  inner  and  outer  walls  of  copper 
water  jacket;  12,  asbestos  layer  insulating  water  jacket. 
15,  water  within  jacket  surrounding  sides  and  floor  of 
bed ;  18,  water  gauge ;  19,  plug  in  opening  used  for  filling 
jacket;  20,  cock  for  emptying  jacket;  22,  removable  crib; 
24,  air  space  underneath  crib;  26,  heating  plate;  28,  rheo- 
stat; 29,  electric  plug. 

3.  Simplicity   of  operation.     It   needs  practically   no 
attention  unless  there  are  extreme  ranges  of  temperature 


464  INFANT  FEEDING. 

in  the  ward,  since  the  asbestos  insulation  prevents 
radiation  from  the  outer  surface  of  the  bed,  and  the 
heater  holds  the  water  at  a  constant  temperature.  It  is 
seldom  necessary  to  change  the  rheostat  more  than 
twice  daily. 

4.  Ease  of  control  of  ventilation  within  the  bed  in 
the  general  wards  of  the  hospital. 

5.  Humidity,  which  is  little  lower  than  that  of  sur- 
rounding air. 

A  COPPER  JACKET  TO  PROTECT  HEATING  PADS. 


Fig.  34. — An  asbesto  -lined  copper  receptacle-  for  electric 
heating  pads  for  use  in  the  care  of  premature  and  debili- 
tated infants  (Hess).  To  avoid  the  danger  of  fire  from 
short  circuits  in  electric  heating  pads,  a  copper  receptacle 
is  used,  16  inches  long,  13  inches  wide,  and  1J4  inches  high, 
into  which  a  12  x  15-inch  heating  pad  is  laid.  To  allow  of 
a  maximum  radiation  from  the  lid  or  upper  surface  of  the 
same,  the  floor  and  sides  are  lined  with  asbestos  sheeting, 
while  the  lid  is  not  lined.  The  cord  passes  through  a  small 
rubber  insulator  at  the  side  to  prevent  contact  with  the 
metal  and  injury  to  the  cord.  This  simple  device  can  be 
used  temporarily  in  wards  and  homes  where  better  facili- 
ties for  the  care  of  this  class  of  infants  are  lacking.  It  is 
to  be  placed  in  the  bottom  of  a  basket  or  crib,  under  the 
mattress  or  pillow. 


APPENDIX.  465 

CASE   HISTORY. 

(A)  PRESENT  ILLNESS. 

1.  Complaints:    Mother's  or  patient's  own  statement. 

2.  Get  history  of  present  illness  in  detail :  Onset,  course 

and  duration.  Fever.  Vomiting.  Stools.  Urine. 
Eruptions.  Sleep,  etc. 

3.  Previous  treatment,  if  any. 

(B)  PREVIOUS  HISTORY. 

1.  Birth:   Para,  nature  and  complications. 

2.  Development:   Teeth  (time  of  eruption),  sat  erect, 

walked,  talked,  mentality. 

3.  General  Health :   Robust  or  delicate,  appetite,  colds, 

fevers,  coughs,  bowels,  convulsions,  mouth- 
breathing,  running  ears,  bed-wetting,  etc. 

4.  Illnesses:    Diseases  similar  to  the  present.     Kind, 

date,  duration,  severity,  recurrences,  complica- 
tions, careful  history  of  acute  infectious  diseases. 

5.  Feeding:  In  detail  in  every  infant. 

(a)  Breast  feeding:   How  long,  intervals,  condition 

of  the  baby,  why  discontinued. 

(b)  Artificial  feeding:  Kind  of  food,  intervals,  how 

prepared,  how  much  at  each  feeding,  total 
quantity,  how  long  used,  effect  on  baby  and 
on  bowels,  why  discontinued. 

(C)  FAMILY  HISTORY. 
Parents,  brothers  and  sisters. 

(Constitutional  diseases:  Tuberculosis,  syphilis,  mis- 
carriages (order  of),  rheumatism,  nervousness  or  insan- 
ity, alcoholism.) 

(D)  EXAMINATION. 
Examine  patient  fully. 

1.  General  appearance  and  weight:  Nutrition  and  gen- 

eral development,  facial  expression  (intelligence, 
pain,  etc.),  amount  of  prostration,  pallor,  cry, 
nervous  condition,  posture,  respiration. 

2.  Skin :  Eruptions,  turgor. 

30 


466  INFANT   FEEDING. 

3.  Temperature:     Pulse    and    respiration    (in    infant 

omit  temperature  until  11). 

4.  Head:     Size,    shape,    fontanelles    (size,    tension), 

cranio-tabes,    eyes,   nose    (mouth,   tongue,   teeth 
under  12). 

5.  Neck:   Goiter,  glands,  rigidity. 

6.  Chest:   Shape,  deformities,  inequalities,  expansions, 

lungs  and  heart  in  detail. 

7.  Abdomen:    Size,  distention,  retraction,  tenderness, 

rigidity,  liver,  spleen,  bladder,  kidney,  fluid  and 
tumors. 

8.  Spine :  Deformities,  rigidity. 

9.  Genitalia  and  genital  region :  Phimosis,  vaginal  dis- 

charge, fissures,  inflammation,  eruptions,  hemor- 
rhoids, pin-worms,  etc. 

10.  Extremities:    Glands,   deformities,   paralyses,   at- 

rophy,  muscle   tone,    reflexes,   athetosis,   swell- 
ing, tenderness,  discoloration,  joints,  gait. 

11.  Temperature :  In  child^under  3  years  always  rectal, 

and  often  in  older  children. 

12.  Mouth:  Teeth,     tongue,     stomatitis,     exanthemata, 
pharynx,  tonsils,  adenoids. 

13.  Middle  ear. 

14.  Special  examinations:    Urine,  blood,  sputum,  cul- 

tures, feces,  vaccinations,  serum  reactions,  etc. 

AVERAGE    WEIGHTS. 


Age 

Boys 
Pounds 

7.55.. 

Girla 
Pounds 

7.16 

Birth 

Six  months 16.50 15.50 

Twelve  months  20.50 19.80 

Eighteen  months 22.80 22.00 

Two  years 26.50 25.50 

Three  years 31.20 , 30.00 

Four  years   35.00 34.00 

Five  years 41.20 39.80 

Six  years  45.10 43.80 

Seven  years   49.50 48.00 


APPENDIX. 


AVERAGE  WEIGHTS — Continued. 


467 


Boys  Girls 

Age  Pounds  Pounds 

Eight  years   54.50 52.90 

Nine  years   60.00 57.50 

Ten  years  66.60 64.10 

Eleven  years  72.40 70.30 

Twelve  years  79.80 81.40 

Thirteen  years   88.30 91.20 

Fourteen  years    99.30 100.30 

Fifteen  years  110.80 108.40 

Sixteen  years  123.70 113.00 

MEASUREMENTS. 

Age  Height  Chest  Head 

in.  in.  in. 

Birth   20.5  13.25  13.75 

6  months   25.0  16.0  17.0 

1  year 29.0  18.0  18.0 

2  years   32.5  19.0  18.75 

5  years   41.5  21.0  20.5 

Head  at  birth,  13.75  inches.  First  year,  gain  4  inches ; 
second  year,  gain  1  inch;  2  to  5  years,  gain  1.5  inches  for 
the  3  years. 

Large  head  and  small  chest  suggests  rickets.  The  head 
is  larger  than  the  chest  until  second  year,  normally. 

GENERAL    DEVELOPMENT. 

A  healthy  infant  speaks  single  words  toward  the  end 
of  the  first  year,  uses  short  sentences  at  the  end  of  the 
second  year ;  sits  erect  at  the  seventh  month ;  stands  with 
assistance  at  ninth  or  tenth  month;  attempts  to  walk  at 
twelfth  or  thirteenth  month,  and  walks  freely  at  the 
fourteenth  or  fifteenth  month. 


SLEEP. 

The  healthy  newborn  infant  sleeps  practically  all  the 
time  except  when  being  fed. 


468  INFANT  FEEDING. 

Hours 
per  day 

At  birth  20  to  22 

At  end  of  1st  year  16  "    18 

During  2d  and  3d  years 12  ''    13 

During  4th  and  Sth  years  10    '    11 

During  12th  and  13th  years  8  fi     9 


ORDER   AND   AVERAGE   TIME   OF   ERUPTION 
OF   THE   TWENTY   DECIDUOUS   TEETH. 

Months 

2  lower  central  incisors  6  to    9 

4  upper  incisors   8  "    12 

2  lower    lateral    incisors    and    4    anterior 

molars   12  "    15 

4  canines   18  "   24 

4  posterior  molars   24  "   30 

At  1  year  should  have  6  teeth. 

At  1  year  6  months  should  have  12  teeth. 

At  2  years  should  have  16  teeth. 

At  2  years  and  6  months  should  have  20  teeth. 

PERMANENT    TEETH. 

Years 

1st  molars  6 

Incisors 7  to    8 

Bicuspids   9  "    10 

Canines   12  "    14 

Second  molars  12  "    15 

Third  molars .  17  "   25 


CLOSURE    OF   FONTANELS. 

Posterior  fontanel  usually  closes  by  the  end  of  the 
second  month.  Anterior  fontanel  at  the  end  of  the  first 
year  is  about  1  inch  in  diameter,  and  usually  closes  at  the 
eighteenth  month.  Normal  variations,  from  fourteen  to 
twenty-two  months. 


APPENDIX. 

AVERAGE   DAILY    QUANTITY   OF   URINE 
IN   HEALTH. 

Ounces 
1st  24  hours  0  to    2 

2d  24  hours ^  «     3 

3  to  6  days  3  «     g 

7  days  to  2  months 5  "    13 

2  to  6  months 7  «    jg 

6  months  to  2  years 8  "   20 

2  to  S  years 16  «  36 

5  to  8  years  20  "  40 

8  to  18  years 32  "  43 

AVERAGE    RATE    OF    PULSE   AND 
RESPIRATION. 

Pulse  Respirations 

Birth   140  35  to  40 

1  month  120  25  "   40 

6  to  12  months 105  to  115      25  "  30 

2  to  6  years  90  "  105      25 

7  to  10  years  80  "  90      22  "  25 

11  to  14  years 75  "  80      20 


BLOOD-PICTURE   IN    HEALTHY    CHILDREN. 

Newborn  Infants  Older  children 

Hemoglobin     110  per  cent.       70  to 95  percent.     65  to 95  per  cent. 
Erythrocytes  5  to  8  millions    4.5  to  5.5  millions    4  to  4.5  millions. 


AVERAGE  WHITE  CELL  COUNTS. 

1.  Healthy  children  between  1  and  15  years  of  age 
average  between  7000  and   15,000  leucocytes,  approxi- 
mately the  same  as  adults. 

2.  Polymorphonuclear  neutrophiles  increase  gradually 
from  30  per  cent,  in  the  first  year  to  about  70  per  cent, 
in  the  fifteenth  year. 

3.  Lymphocytes  decrease  from  60  per  cent,  in  the  first 
year  to  about  30  per  cent,  in  the  fifteenth  year.     (This 
represents  combined   (large  and  small)   lymphocytes.) 


4/0  INFANT   FEEDING. 

4.  The  reversal  of  the  percentages  of  neutrophiles  and 
lymphocytes  occurs  usually  about  the  sixth  year. 

5.  Eosinophiles  average  between  4  to  6  per  cent.,  but 
vary  greatly  in  different  children  at  the  same  ages. 

6.  Transitional  cells  average  approximately  2  to  3  per 
cent.,  not  varying  greatly  at  the  different  ages. 

7.  Mast-cells,  about  0.3  to  0.6  per  cent.     Frequently 
absent. 

8.  Large  mononuclear  neutrophiles,  1  to  3.3  per  cent. 
About  the  same  at  different  ages. 

Stool  symbols  Urine  symbols 

N  =  normal.  A  =  albumin. 

S'=  soft.  S  =  sugar. 

W  =  watery.  Ac  =  acetone. 

F  =  fat-soap.  D  =  diazo. 

M  =  mucus.  I  =  indican. 

Bl  =  blood.  C  =  casts. 

C  =  curds.  P  =  pus. 

G  =  green.  Bl  =  blood. 

Ep  =  epithelium. 

GRAPHIC  RECORD  SHEET. 

A  brief  description  of  the  clinical  sheet  used  in  our 
wards  may  be  of  value,  as  it  answers  both  the  needs 
of  a  history  sheet  and  of  a  daily  chart  as  well.  The 
points  illustrated  by  it  are:  A  graphic  relationship 
between  the  temperature,  weight,  quality,  and  quan- 
tity of  food  taken,  and  the  end-results  on  the  stools 
and  urine.  Also  separate  spaces  are  provided  for 
complications  which  may  influence  the  preceding 
under  the  heading  of  symptoms,  together  with  spaces 
for  treatment  other  than  dietetic-,  energy  value  of 
foods,  vomiting,  blood  examinations,  tuberculin  re- 
actions, etc.  The  small  figures  1-10  are  used  to  make 
an  electrical  reaction  curve  in  cases  showing  a  spas- 
mophilic  diathesis. 


APPENDIX. 


471 


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472 


INFANT  FEEDING. 


DEPARTMENT    OF    PEDIATRICS 

UNIVERSITY    OF  ILLINOIS     -   .- —     COLLEGE  OF   MEDICINE 


nd    laler    d.v.!o 


PREVIOUS    ILLNESSES 


FEEDING    HISTORY 


ARTIFICIAL  FEEDING.  In 


FAMILY  HISTORY 


473 


474  INFANT  FEEDING. 


TEMPERATURE P  R 

LABORATORY  EXAMINATIONS 


TRKATMKNT 


ASSIGNED    TO 


APPENDIX. 


475 


SUBSEQUENT   TREATMENT    AND    REMARKS 


476  INFANT  FEEDING. 


I3FAXT  WELFARE  CONFERENCE 


Telephone House    Flat    Front    Rear    Floor 

Guardian's  Name Relationship. 

Sex Age Date  of  birth 


Referred  by 

Clinician  Cross  Indez.        Ye 

WHY  IS  INFANT  BROUGHT  TO  THE   CONFERENCE?      (Mother's   answer) 


(Does  she  think  It  Is  normal?) 

HISTORY  OF  PRESENT  ILLNESS   (Onset,  duration  progress): 


FAMILY  HISTORY 

Name  Birthplace  Living      Dead      Age      Condition  at  Health      Cause  of  Death 


Children  Condition 

No.  Duration  Delivery  of  Health 


Miscarriages 

No.  Order   of  Pregnancies      Months 


PERSONAL  HISTORY 

Full-term Premature  at months       Birth  Wg 

Condition  at  birth 

Teeth:       First  at mos       Sat  erect  at mos.        Walked  at 

Talked:     Simple  words  at mos.        Short  sentences mos. 

Mental   development — — 


PAST  ILLNESSES: 

Diarrhea  Rickets  Bronchitis 

Snuffles  Spasmophilia  Pneumonia 

Colds  Convulsions  Otitis 

Adenitis  Tonsillitis  Measles 


Operations . „___ 

Important  details  and  other  diseases. 


APPENDIX. 


Mumps  Pertussis  Pyelitis 

Scarlet  Fever  Chicken  Pox  Scurry 

Influenza  Eczema  Acidosit 

Diphtheria  Enuresis  Syphilis 


477 


Rheumatism 
Chorea     . 
Endocarditis 

Nephritis 


FEEDING  HISTORY: 

Breast  fed  Bottle  Mixed 

Do  you  nurse  baby  now? How  often? Hours 

How  long  do  you  leave  the  baby  at  the  breast? minutes.  Does  the  baby  empty  the  breasts? 


-On  one  or  both  breasts? 


Quality  of  BREASTS  good,           fair,           poor;                   NIPPLES  good,           bad.           Inverted. 

Hnw  Inup  rtirt  vnii  Tinrse  thp  hahv  piclnsivelv?                   months       Part  niinslng 

months 

H'hy  did  y>«  •lis'"«ntfn'i'>  part  nursing' 

Why  rti.J   vnn    riieonntiniia   al]    nursing'                                                                       

ARTIFICIAL   FEEDING   HISTORY   TO  PRESENT  TIME 


PRESENT  FEEDING  IF  0\  BOTTLE 


Interval 

MIXTURE: 


.  Amount  of  each 


Milk  (certified,  pasteur,)- 
Water  (plain  or  cereal)— 

Sugar  (kind) 

Other    ingredients 


_c  c  orounces. 
_c  c  orounces. 
tablespoonful  (level). 


Is  the  mixture  fed  raw,  pasteurized  or  boiled? 
Other  foods  taken  amount 


Does  the  baby  take  all  of  the  fcedings?_ 
Foods  refused  


Food  idiosyncrasies  (milk,  cereal,  fruits,  vegetables,  meats  and  eggs) 

Docs  the  baby  vomit? How  much 

Does  the  baby  have  colic? When — : — 


How  many  times  a  day  do  the  bowels  move  (average).    Well,  sick  . 
Color Consistency Mucus 


478 


INFANT  FEEDING. 


PHYSICAL     EXAMINATION 


___Respirati< 

Dull 

Fat  Thin 

Prickly  Heat 
Urticaria 

MUSCLES:    Biceps  and  Thighs  Firm 

HEAD:     Normal 


Temperature Pula 

INSPECTION.    Bright 
GENERAL  CONDITION: 
SKIN:  Normal 

Tissue  Turgor 


(Underline  each   word  describing  condition) 

Nervous  Phlegmatic  Apathetic 

Good  Fair  Poo? 

Eczema  Scabies  Scborrbe* 

Impetigo  Pediculosis  Nails 

Flabby 

.Fontanelle 


Cranio-tabes. 
EYES:    Pupils  equal 
Motion 
NARES:    Clear 

SINUSES:     Maxillary 
MOUTH:        Normal 
TONGUE:      Normal 
THROAT:      Normal 
TONSILS:      Normal 
GLANDS:       Normal 

Unequal 
s:                       Norma 

Crushed            Discha 

React  to  light                 Distance                 Nystagmus 
1                 Abnormal                 Blepharitis                 Strabismus 

,1 

Ethmoid- 

Open     , 
Moist 
Injected 
Large 
Enlarged 

Herpes 
Dry 

Buried 
Ant.  -cervical 

Stomatitis 
Injected 
IT*) 

(type) 

Cryptic                Inflamed  Operated  Stumps  Adenoids  
Post-cerv.                Epilroclear  Inguinal                Others 

TEETH: 
EARS: 
NECK: 
CHEST: 
LUNGS:_ 

Mr, 

r.™(                  No 

Decayed  Approj 
left.      Discharge      right 

Olhor 

Normal 

Perforation      right 

Irft.       rharartM- 

Normal 

barrel            flat 

funnel 

pigeon 

Rosary            Harrison's  Groove 

_D'Espine_ 


HEART:    Area  of  dullness_ 


Apex  4th 


_cm  to  left  of  mid-sternal  line 

_cm  to  right  of  mid-sternal  line 
6th  space  in  mid-clavicular  line 


Action:    Regular 
Murmurs:    NONE 

N  Soft  ' 
Loud 

Irregular 
presystolic 
systolic 
diastolic 

Sounds:    clear           impure 

1  •  1 
apex 

aortic                                           

RInnd  Pro.-r.ure 

ABDOMEN:       Normal 
Hernia 

large 
umbilical 

distended                   tympanitic                tender 
inguinal                     right                           left 

_                                                 > 

LIVER: 
SPLEEN: 

Palpable  Enlarge 
Palpable            Yes 
a.                Bi^ht 

d  Bou 
No 

nHor,W  in  MM    PI  I. 

Si™ 

T.»f» 

GENITALS:                Phimosis 
Anus 
EXTREMITIES:        Deformity 

Circumcised                Undesccndcd      Testicle      Hydrocele      Vaginitis 
Normal                     Abnormal 
Acquired                   Congenital                                              Rickets 

FEET:    Arches      good  flat      pronated      Posture      good      poor      Gait __ 

SPINE:     Normal  Rigid                Curvature  Round  Shoulder 

REFLEXES:     Patcllar                Brudzinski                Oppcnheim  Trousseau 
Kcrnig                           Babinski                       Chvostek 

Present-™ , 


WEIGHT 
LENGTH 


Present- 


-Normal  for  hcight_ 
-Normal  for  weight- 


Ant. 
CIRCUMFERENCE: 


up.  spine  to  vertex — 
Head  Chest 


Ai'i'KXDix.  479 


LABORATORY  AND  SPECIAL  EXAMINATIONS 
URINE:  Color  Sp.gr.  K^^ 

Susar  Acetone  Diacetic  Acid 

Pus  Blood  Cute 

SPECIAL  XOSE,  THROAT,  EAR  and  SINUS: 

EYE:  ~ 


HADIOGRAM  OF  CHEST,  DIGESTIVE  TRACT,  etc 


BLOOD:  R.  B.  C.  Hemoglobin  Diff.  Ct.  Co«f.  Time 

Vaccination 

Throat  Culture: 

Von  Pirquet:  negative  positive  cm.  areola 

Vaginal  Smear 

Electrical  Reactions:  COC  AOC  Relation  AOC  to  ACC 

Slm-k  Test: 

Skin  Test  for  Proteins. 

Stool  Exam,  for  Parasites. 

Toxin  Antitoxin: 

SUMMARY  OF  DEFECTS  FOUND 

Underweight  for  height  pounds  per  cent 

Carious  Teeth  No.  alveolar,  abscesses 

Mouth  Breather  Cryptic  Tonsils  Rt 

Enlarged  Cervical  Glands 

Otitis:  dry  discharging  R.  L 

OTHER  PATHOLOGICAL  FINDINGS 


RECOMMENDATIONS : 

Feeding 


Hygiene 
Social  Service 

CONSULTATIONS  ORDERED: 

Consultations  reports  received  and  operations  performed- 


SOCIAL  SERVICE  REPORT 

Neighborhood  Home 

Bath  tub  sanitary  conditions  In 

Mother's  attitude  Remarks 


480  INFANT  FEEDING. 


CHILD   WELFARE    CONFERENCE 


Name 

Addr< 


House    Flat    Front    Rear    Floor. 


Guardian's  Name Relationship. 

Sex : Age Date  of  birth 


Referred  by 1 

Clinician  Cross  index.       Te 

WHY  IS  CHILD  BROUGHT  TO  THE  CONFERENCE!         (Mother's  answer) 


(Does  she  think  It  Is  normal?) 

HISTORY  OF  PRESENT  ILLNESS  (Onset,  duration  progress): 


FAMILY  HISTORY 

Name  Birthplace  Living      Dead      Age      Condition  of  Health      Cause  of  Death 


Children  Condition  Age  at  Cause  of 

No.  Duration  Delivery  of  Health  Age  Death  Death 


Miscarriages 

No.  Order  of  Pregnancies      Months 


PERSONAL  HISTORY 

Full-term Premature  at months       Birth  Wg 

Condition  at  birth 

Teeth:      First  at mos.      Sat  erect  at mos.        Walked  at_ 

Talked:     Simple  words  at mos.        Short  sentences mos. 

Mental  development — _ : 


APPENDIX. 


481 


PAST  HLXES8E8: 

Diarrhea                 Rickets 
Snuffles                  Sp.ismophilia 
Colds                     Convulsions 
Adenitis                  Tonsillitis 

Bronchitis 
Pneumonia 
Otltls 
Measles 

Mumps                 Pertussis 
Scarlet  Fever       Chicken  Pox 
Influenza               Eczema 
Diphtheria            Enuresls 

Pyelltls 
Scurvy 
Acldosls 
Syphilis 

Rbenmatisn 
Chorea 
Endocarditis 

Nephritis 

Important  details  and  other  diseases 

PHYSICAL  EXAMINATION 

—  Respiration  (Underline  each 
Dull                 Nervous                  Phlegmatic 

word  describing  condition.) 
Apathetic 

INSPECTION  : 

Bright 

INSPECTION  :    Bright                 Dull 

ic  eatn   wora  aescnoing  condition.) 
Nervous                  Phlegmatic                Apathetic 

GENERAL   CONDITION:       Fat          Thin 

Good          Fair          Poor 

SKIN: 

Normal                            Prickly  Heat 

Eczema 

Scabies 

Seborrhea 

Tissue  Turgor                Urticaria 

Impetigo 

Pediculosis 

Nails 

MUSCLES:      Biceps  and  Thigh             Firm 

Flabby 

HEAD:      Normal         Bosses  prominent  

Oanln-lahna 

EYES:    Pupils  equal            Unequal            React  to  light          Distance 

Nystagmus 

Motions:           Normal            Abnormal             Blepharitis 

Strabismus 

IT  ABES  I    Clear 


SINUSES:     Maxillary. 

*v™t,l                                               WTnn.,1                                            S   >..n«M 

MOUTH  :      Normal 
TONGUE:      Normal 
THROAT:      Normal 
TONSILS:    Normal 
GLANDS:    Normal 

Open           Herpes           Stomatitis  (type) 
Moist           Dry           Injected 

Injected               Momhr.no    (type) 

Large          Burled          Cryptic       Inflamed  Operated  Stumps  
Enlarged          Ant-cervical            Post-cerv.           Epitroclear  Inguinal 

-Adenolds__ 

Others 

TEETH:  No 

EARS:      Normal    Perforation    right    left. 

NECK:       Thyroid 

CHEST:    Normal 
LUNGS:   


No.  Decayed Approximation  good  poor.  Alveolar 

Discharge    right     left     character 

Other   finding. 


barrel 


flat 


funnel 


pigeon 


Rosary 


Harrison's  Groove 


HEART:    Area  of  dull: 


Apex  4th 


-cm  to  left  of  mid-sternal  line 
_cm  to  right  of  mid-sternal  line 
6th   space  la   mid-clavicular  line 


Action:     Regular         Irregular         Sounds: 
Murmurs:    NONE 
presystollc 
Soft 
systolic 
Loud 
dlastollc 

clear        Impure 

ABDOMEN:        Normal          large              distended 
Hernia          umbilical           inguinal 

tympanltic             tender 
right            left 

-Blood  Pressure- 


LITER:  Palpable- 
SPLEEN:  Palp-hie 
Kidneys:  Right 


—Enlarged Boundaries  In  Mid.  Cl.L. 

Tes          No  Size 


31 


482  INFANT  FEEDING. 


GENITALS:  Phimosis  Circumcised  Undescended    Testicle    Hydrocele    Vaglnltls 

Anus  Normal  Abnormal 

EXTBEMITIES:        Deformity  Acquired  Congenital  Rickets 


FEET:      Arches    good  flat    pronated    Posture  good  poor   Gait 

SPINE:    Normal  Rigid  Curvature  Round  Shoulders 

BEFLEXES:    Pateliar  Brudzinski  Oppcnheim  Trousseau 

Kernig  Babinski  Chvostek 

WEIGHT:       Present Normal  for  height 

LENGTH:      Present Normal  for  weight 

Ant.  sup.  spine  to  vertex to  sole  

CIBCl'MFEKEXCE:    Head  Chest  Abdomen- 


DIET  AND  HYGIENE. 

Appetite  (Especially  for  Breakfast'  -good  fair  poor 

Breakfast  Between  Dinner  Between  Supper 

Regularity  of  meals— hours 

Food  dislikes  

Food  Idiosyncrasies  (milk,  cereals,  meat,  eggs,  vegetables,   fruits)   


Nn    of  rhilrtrpn  in    family                             ABpa 

'Milk  purchased  daily 
Milk  taken  daily 
Cereal 
Vegetables           potatoes           other 
Fruit 
Meat  or  fish  or  eggs 
Coffee 
Tea  ' 
Candy                How  much                When  eaten 

Rest  periods           yes 
Sleep               quality 
quantity 
No.  sleeping  In  room 
Fresh  air 
Out  or  doors 
Teeth                      How 
Bath 
Constipated  yes  or  no 

sound              restless 
hours 
1n  hi"1 

window  open 
Hours 
often  brushed 

Use 

closed 
of  cathartics 

LABORATORY   AND   SPECIAL  EXAMINATIONS 
CBINE:  Color  Sp.   gr.  Reaction 

Sugar  Acetone  Diacetlc  Acid 

Pus  Blood  Casts 

SPECIAL  NOSE,  THROAT,  EAR  and  SINUS: 


RADIOGRAM   OF  CHEST,  DIGESTIVE  TRACT,  etc.: 


BLOOD]  W.  B.  C.  R.  B    C.  Hemoglobin  Diff.  Ct. 

Vaccination : 

Wassennan  Reaction- 

Throat  Culture: 

Von  Pirquet:  negative  positive          cm.  areola 

Vaginal  Smear 

Electrical  Reactions:  COC  AOC  Relation  AOC  to  ACC 

Shick  Test: 

Skin  Test  for  Proteins: 

Stool  Exam,  for  Parasites: 

Toxin  Antitoxin: 

SUMHABY  OF  DEFECTS  FOUND 

Underweight  for  height  pounds  per  cent 

Carious  Teeth  No.  alveolar    abscesses 

Mouth  Breather  Cryptic    Tonsils  Rt 

Enlarged  Cervical  Glands 

Otitis:  dry  discharging  R. 


APPENDIX. 


483 


OTHER  PATHOLOGICAL  FINDINGS- 


RECOMMEND  ATIOXS: 

Feeding 


Hygiene 
Social  Service 


(OYsn.T  \TIO\S  OBDERED: 

Consultations  reports  received  and  operations  pertormcd- 


Nelghborhood 

Bath  tub  sanitary  conditions 

Mother's  attitude  Remarks. 


SOCIAL  SEKTICE  REPOBT 

Home 


SUBSEQUENT  TREATMENT 


DATE   TEMP.   WGT 


484 


INFANT  FEEDING. 


SUBSEQUENT  TREATMENT 


Dale  Age         Wright       Tei 


INDEX. 


Abdomen,  condition  of,  in  over- 
feeding, 74 
Acetone  bodies,  13 
Acetone  body  adicosis,  394 
Acetonuria,  385 

from    inanition,   394 
Acid,  excess  of,  in  tissues,  388 

excreted  by  renal  tissues,  388 

hydrochloric,  presence  of,  3 

lactic,   in  tissues  in  acidosis, 
261 

neutralizing  of,  389 
Acidity,  in  stomach  of  normal 

breast-fed,   243 
Acidosis,  384 

acetone  body  in,  390 

alkali  therapy  in,  402 

diet  in,  403 

in  anhydremia,  266 

in  athrepsia,  242,  248 

lactic  acid  in  tissues  in,  261 

medical  treatment  of,  404 

of  renal  origin,  397 

physiological,    at    birth,    394 

post-operative,  3% 

prognosis  in,  400 

pulmonary  diseases  in,  392 

treatment  of,  401 

secondary  to  burns,  397 

symptoms  of,  397 
Acids,  cause  of  excess  in  intes- 
tines, 241 

volatile,  in  milk,  105 
Active    signs    in    spasmophilia, 

353 

Air  hunger  in  acidosis,  398 
Albumin    milk,    cause    of    in- 
creased intestinal  secre- 
tion, 23 


Albumin    milk,    formulas    for, 

444,  445 

in  athrepsia,  255 
in  diarrhea,  234 
in  cnteral  infections,  300 
in  infection,  282 
in  beef  extract,  433 
water,  432 

Alkali  therapy  in  acidosis,  402 
Amino    acids    in    diarrhea,    in 

anhydremia,    261 
Ammonia  in  urine,  neutralized 

by  acids,  389 

Anatomy  of  digestive  tract,  1 
Anemia,  aplastic,  417 
Banti's  disease  in,  418 
blood  findings  in,  413 
blood  transfusion  in,  423 
causes  of,  406 
chlorotic  type  of,  416 
following  hemorrhage,  409 
hemolytic  icterus  in,  418 
in  prematures,  408 
nutritional     disturbances     as 

cause  of,  410 
of  infancy,  405 
pernicious,  4lT 
prognosis  of,  421 
splenectomy   in,  424 
splenic  enlargement  in,  413 
symptoms  of,  412 
treatment  of,  422  . 
von  Jaksch's,  415 
Anions,  15 
Anhydremia,  259 
acidosis  in,  266 
changes  of  blood  in,  265 
diagnosis  of,  269 
diet  in,  274 

(485) 


486 


INDEX. 


Anhydremia,  etiology  of,  259 

heart  action  in,  265 

intoxication,  281 

nervous  symptoms  in,  264 

pathogenesis  of,  266 

respiratory  manifestations  in, 
264 

symptoms  of,  262 

urine  in,  264 

water  administration  in,  270 
Antiscorbutics,  fruit  as,  381 
Appendix,  425 
Argyrol  in  diarrhea,  236 
Athrepsia,  237 

causative  factors  in,  238 

cell  hunger  as  cause  of,  239 

diagnosis  of,  248 

differentiation    from    chronic 
infections,  238 

hunger  day  in,  danger  of,  244 

medical  treatment  of,  257 

pathogenesis  of,  239 

prognosis  in,  249 

symptoms  of,  244 

treatment  of,  250 
Atropine,   use   of,    in    diarrhea, 
236 

Baby  foods   (proprietary),  425 
Bacilli  in  enteral  infections,  293 
Bacteria,  cause  of  anemia,  411 
content  in  milk,  106 
diseases  due  to,  34 
in  enteral  infections,  284,  286 
influence  of  diet  on,  30 
intestinal,  cause  of  fermenta- 
tion, 33 

signification  of,  29 
invasion    in    upper    intestinal 

tract,  243 
relation     to    gastro-intestinal 

disturbances,  32 
Barley  water,  431 
Bath,  hot,  454 
hot  and  cold  packs,  453 


Bath,  mustard,  454 
Bile,  functions  of,  4 
Blood,  calcium  content  in  nor- 
mal infants,  316 
changes  in  acidosis,  265 
findings  in  anemia,  414 
picture    in    healthy    children, 

469 

in  normal  infants,  405 
vessels,  changes  of,  in  scurvy, 

371 
volume,  average,  in  athrepsia, 

240 
Bone    marrow,    changes    in,    in 

scurvy,  368 
salts,  increased  by  phosphorus 

intake,  317 

Bottles  and  their  care,  447 
Bowel  irrigation,  in  overfed,  78 
Brady's  mixture,  No.  1,  436 

No.  2,  437 
Breast-milk,  cause  of  excess  fat 

in,  77 

conditions  influencing  qual- 
ity of,  41,  55 
feeding,       preventive       of 

scurvy,  380 
how  to  express,  58 
idiosyncrasy  toward,  82 
instructions  for  expressing, 

58 

insufficient    supply,    indica- 
tions of,  in  infant,  69 
method  of  drawing,   56 
number    of    daily    expres- 
sions, 60 
quantity  required  by  infant, 

68" 
Breasts,  massage,  as  applied  to, 

71 
care  of,  40 

during  weaning,  66 
means  of  stimulating,  70,  71 
steaming  of,  71 
Burns  as  cause  of  acidosis,  397 


INDEX. 


487 


Butter-flour    feeding,   446 
Buttermilk  and  skimmed   milk- 
mixtures,  435 

for  hospital  feeding,  435 

in  home,  434 

Calcium,  content  in  milk,  14 

level  disturbance  a  factor  in 
rickets,  309 

metabolism,    relation    of   diet 

to,  318 
in  spasmophilia,  345 

relation  to  spasmophilia  symp- 
toms, 346 

salt,  diminution  of,  factor  in 

spasmophilia,  349 
Caloric  content  of  foods  in  cor- 
rect feeding,  135 

needs,  definite  estimation  of, 
136 

requirement     for     artificially 
fed  infant,  136 

value  of  various   foods,   138, 

146 
Calories,  energy  quotient  in,  138, 

146 
Camphor,  use  of   in  athrepsia, 

257 

Cane  and  milk  sugars,  129 
Carbohydrate,        addition        to 
breast-milk,  in  athrep- 
sia,  252,   253 

amount  for  infant,  153 

amount  needed  by  infant,  130 

as  cause  of  increase  in  diar- 
rhea, 260 

chemistry  of,  11 

disorders  due  to  fermentation 
of,  34  ' 

effect  of,  on  weight,  13 

factor  in  diarrhea,  221 

fermentation      produced      by 
bacteria,  33 

in  corn  syrup,  254 

in  infection,  282 


Carbohydrate,  in  tissues,   13 
increase  in   severe  athrepsia, 

256 
influence   on   development  of 

bacteria,  31 
insufficiency,     symptoms     of, 

204 

intestinal  reaction  to,  203 
metabolism  of,  12 
precautions  in  administering, 

130 
starvation,     danger     of,      in 

diarrhea,  234 

to  be  added  to  feedings,  142 
use  of,  128 
Care   of   infant's    food    during 

travel,  449 
Case  histories,  465 
Castor  oil  in  convulsions,  356 

in  enter al  infections,  297 
Cathartics  as  cause  of  diarrhea, 

225 

Catheter  feeding,  457 
Cations,   14 
Cell  hunger,  239 
Cereal  water,  addition  to  diet, 

143 

flours,  131 

Chlorine  content  in  milk,   15 
Cholesterin  content  in  milk,  18 
Chvostek's  sign  in  spasmophilia, 

352 
Chymogen  milk,  434 

in    irritable    stomach    con- 
ditions, 301 
Codliver    oil,    phosphorized,    in 

rickets,  339 
Colic,  167 
associated    with   constipation, 

168 

in  overfed,  78 
treatment  of,  169 
Colon  irrigation  and  rectal  feed- 
ing, 457 
Colostrum,  7 


488 


INDEX. 


Condition    of    infant,    how    es- 
timated, 229 
Constipation,   170 
associated  with  colic,   168 

with  soap  stools,  205 
boiling  milk,  as  factor  in,  111 
diagnosis  of,  174 
dietetic  errors  in,  173 
relieved      by      addition      of 
vegetables  in  diet,  177 
treatment,  175 

in  enteral  infections,  302 
Convulsions,  castor  oil  in  treat- 
ment of,  356 
due  to  salt  excess,  treatment 

of,  403 
result    of    overfeeding    with 

fat,  128 
seditive    for,    in   anhydremia, 

274 

Cream  and  skimmed  milk  mix- 
tures,  155 

Crying   of   infant   in  overfeed- 
ing, 78 

Daily  gains  in  weight,  of  pre- 
matures, 96 

Data  as  to  foods  and  food  re- 
quirements, 139 
Debility,  congenital,  impairment 

of  functions  in,  79 
prematurity  as  cause  of,  79 
Defective    hygiene,     factor    in 

rickets,  312,  334,  338 
Dextrinized  barley,  432 
Diaper,  450 
Diarrhea,  as  accompaniment  of 

acidosis,  398 

cathartics  as  factors  in,  225 
chronic,  235 
chronic  disease,  as  cause  of, 

225 

differential  diagnosis  in,  228 
due  to  overfeeding,  220 
factors  in,  218 


Diarrhea,  from  infected  foods, 
222 

from  infections,  223 

from  overfeeding,  74 

from   subnormal    food   toler- 
ance, 222 

idiosyncrasy  as  factor  in,  224 

in  infections,  290 

increase  due  to  carbohydrates 
and  fat,  260 

sequel     to     nutritional     dis- 
orders, 218 

temperature,  as  factor  in,  223 

treatment  of,  230 

varieties  of,  228 
Diet,    clinical    findings    of,    in 
rickets,  311 

constituents  of,   as   factor   in 
digestion,  123 

effect  of  in  spasmophilia,  343 

fruit  juices  and  vegetables  in 
rickets,  333 

hunger,  in  diarrhea,  231 

in  acidosis,  403 

in  anhydremia,  274 

in  convalence  from  enteral  in- 
fections, 302 

in     late    infancy    and    early 
childhood,  158 

indifferent,  in  diarrhea,  231 

injury  from,  211 

of   lactating   mothers,    factor 
in  rickets,  307,  332 

mixed,  for  young  infants,  145 

relation   to   calcium    metabo- 
lism, 318 

Digestion,    constituents   of   diet 
in,    123 

of  fat  by  infant,  127 

of  milk,  22 

Digestive  tract,  anatomy  of,  1 
Dilution  of  milk  for  prematures 

in  first  days,  91 
Disaccharides,  11 
Diseases  due  to  bacteria,  34 


INDEX. 


489 


Disorders  due  to  carbohydrate 

fermentation,  34 
dependent   on    vitamine   lack, 

215 

Drugs,  effect  of,  on  milk,  42 
Dyspepsia,   result  of   overfeed- 
ing, 75 

Eclampsia,   354 

as  result  of  overfeeding,  75 
Edema,  caused  by  flour  injury, 

213 

Eggs,  442 
Endocrine     gland     theory,     in 

rickets,  313 
Enteral      infections,      diagnosis 

of,  292 

complications  of,   292 
diatetic  treatment  of,  299 
medical  treatment  of,  298 
stimulants  in,  298 
treatment  of,  296 
Enteritis,  285 

prognosis  in,  295 
Epinephrin,    in    athrepsia,   257 

in  diarrhea,  236 
Erb's  sign  in  spasmophilia,  351 
Excretion,  effect  of  fat  on,  15 
of  calcium,  14 
of  chlorine,  14 
of  iron,  14 
of  salts,  15,  24 
of  sodium,  14 

Farina  and  other  gruels,  432 
Fat,    as    cause    of    increase    in 

diarrhea,  260 
digestion  in  infants,  152 
effect  on  stool  formation,  24 
influence,      on      fermentative 

processes,  31 

metabolism,  abnormal,  essen- 
tial factor  in  athrepsia, 
242 
requirement  in   feeding,   140 


I  ats,  amount  necessary  for  in- 
fants, 128 

as  cause  of  increased  excre- 
tion, 15 

as  cause  of  vomiting,  128 
chemistry  of,  10 
in  breast-milk,  11 
in  gastro-intestinal  tract,  11 
in  urine,  10 
metabolism  of,  10 
necessary  for  heat  energy,  127 
result  of  excess,  203 
Fatty      acids,      appearance     in 

stools,  227 
Feces  in  breast-fed,  residue  in, 

62 

test   for  constituents  in,  24 
Feeding,  artificial,  during  first 

weeks,  151 
factor  in  rickets,  309 

in  athrepsia,  252 
by  catheter,  in  parenteral  in- 
fections, 81 

catheter,  in  prematures,  87 
diets  in  late  infancy,  158 
example,   No.   1,  147 
No.  2,  149 
No.  3,  150 
formulas,  148 
in  weak  infants,  85 

regular  time  for  beginning, 

90 

method  of  bottle,  152 
methods  with  prematures,  86 
mixed,  63 
of  prematures,  84 
an  individual  problem,  92 
first  ten  days,  93 
requirements    by   weight,  63 
Feedings,  amount  of,   for  pre- 
matures, 95 
artificial,   in   prematures,  96 

recent  progress  in,  100 
boiled    buttermilk    mixtures, 
for  prematures,  97 


490 


INDEX. 


Feedings,  chymogen  milk  in,  98 
during  first  days,  45 
of  prematures,  number  neces- 
sary per  day,  94 
maximum  in  first  ten  days,  in 

prematures,  96 
number  of,  in  24  hours,  43 
percentage  method  of,  117 
quantity  and  quality  of,  97 
required  in  24  hours,  141 
top  milk,  118 
Ferments,  in  stomach,  4 
intestinal,  4 
normal  in  milk,  102 
pancreatic,  4 
Flora  of  intestines,  28 
Flour  ball,  211,  432 
edema  from,  212,  213 
injuries,  211 

Fontanelles,  closure  of,  468 
Food,    elements    required,    per 
pound  body  weight,  140 
reaction  to,  in  healthy  infant, 

197 

refusal  in  infection,  284 
requirement  in  estimation  of 

diet,  139 
supply,  effect  on  body,  from 

insufficient,  240 
tolerance,    subnormal,    nutri- 
tional   disturbance   due 
to,  195  " 

Foods,  caloric  value  of,  138,  146 
diet  of  artificial,  in  pathogene- 
sis    of    nutritional    dis- 
turbance, 207 
to  be  avoided,  161 

taken  with  caution,   161 
Foodstuffs,  classes  of,  20 
value  of,  in  scurvy,  365 
Fruits,  as  antiscobutics,  365,  381 
apple  sauce,  442 
orange  gelatine,  442 
juice,  19,  41,  145,  153,  365, 
382,  422 


Fruits,  prune  jelly,  442 
juice,  41 

Galactose  in  milk,  11 

Gas     bacillus,     cultured     from 
stools,  294 

Gastric    juice,    present    in    pre- 
matures, 3 

Gavage,  size  of  meal,  important 
in,  2 

General  development  of  infants, 
467 

Glucose   administration,  in  aci- 

dosis,  395,  404 
in  athrepsia,  254 
solution,     intravenous     injec- 
tion   of,    in    athrepsia, 
258 

Glycogen,  formation  of,  12 
found  in  new-born,  4 
stored  by  liver,  12 

Gram-positive  bacilli,  28 

Gruel,  432 

Heat,    as    cause    of    nutritional 

disturbance,  196 
artificial,  in  athrepsia,  258 
Heating  pad  receptacle,  464 
Hunger  day,  in  athrepsia,  dan- 
ger of,  244 

diet  in  severe  athrepsia,  256 
Hydrochloric  acid,  3 

Ice-box,  home  made,  461 
Idiosyncrasy  to  cow's  milk,  186 

toward  mother's  milk,   57 
Indigestion,  gastric,  acute,  165 
Infant  bed,  Hess,  462 

foods,  direction  for  prepara- 
tion of,  431 

Infant's  gelatine  food,  443 
Infection  and  nutrition,  276 

as  cause  of  diarrhea,  223 
Infections,  etiology,  284 

changes  produced  by,  280 


INDEX. 


491 


Infections,  chronic,  392 
cnteral,  284 
pathology  of,  287 
sequel  to  parenteral,  285 
intestinal,  inflammation  in,  288 
of  upper  respiratory  tract,  392 
of  upper  respiratory  tract,  as- 
sociated with   acidosis, 
390 
parenteral,  279 

inert  fluids  in,  81 
relation  to  scurvy,  362 
symptoms  of,  280,  289 
treatment  of,  281 
Infectious  disorders,  acidosis  in, 

390 

Intestines,  flora  of,  28 
large,  function  of,  5 
relative  size,  21 
Intraperitoneal    injections,  402 
Intravenous     saline     injections, 

460 

Iron  content  in  milk,  14 
metabolism,  411 

Kations,  14 

Keller's  malt  soup,  437 

Lactation,  period  of,  55 

Lactic  acid-corn  syrup  mixture, 

254 

Lamb  and  veal  broth,  438 
Laryngismus  stridulus,  354 
Lavage,  88 

Lecithin,  content  in  milk,  18 
Length  increase,  first  year,  61 
Leukemia,  acute  lymphatic,  419 

splenomyelogenous,  421 
Light,  action  of,  in  rickets,  312 
Lime  water  in  milk,  144 
Lipoids,  17 
Liver,   secretions  of,  4 

size  of,  2 

Magnesium,  content  in  milk,  14 
Maltose  and  dextrin  compounds, 
131 


Measurements,  467 
Meats,  447 

Metabolism,  definition  of,  6 
in    infections,    difficulties    in 

study  of,  6 
of  calcium,   in   spasmophilia, 

345 

of  fat,  10 
of  iron,  411 

of  minerals  in  rickets,  313 
of  nitrogen,  9 
of  phosphorus,  317 

in  normal  infants,  346 
of  salts,  in  infants,  15 
relation  of  salts  to,  15 

of  water  to,  16 
Milk,  adaptations,  115 
ageing  of,  a  factor  in  scurvy, 

360 

albumin,  444,  445 
administration,   guarded   in 

athrepsia,  256 
cause    of    increased    intes- 
tinal secretion,  23 
duration  of   feeding  of,  in 

athrepsia,  257 
in  athrepsia,  255 
in  diarrhea,  234 
in  enteral  infections,  300 
bacterial  content  of.  106 
boiling,  as  factor  in  constipa- 
tion,   111 
method  of,  114 
sterilizing  and  pasteurizing, 

110 
boiled,   advantage   over   raw, 

112 

buttermilk,  in  enteral  infec- 
tions, 300 

breaking  curd  in,  144 
breast,   as   curative   agent    in 

spasmophilia,  343 
conditions    influencing,    41, 

55 
methods  of  drawing,  56 


492 


INDEX. 


Milk,  certified,  107 

versus  boiling,  114 
chymogen  or  pegnin,  98 

in  enteral  infections,  301 

in  infection,  284 
cooling,  importance  of,  107 
cow's,  103 

and  human  compared,  104 

begin  use  of,  64 

difference    from    maternal, 
103 

in    aggravation    of    tetany, 
343 

in  anhydremia,  275 

low  in  antiscorbutic  factors, 

360 

digestion  of,  22 
dilution,   for  prematures,  91 

with  carbohydrates,  138 
dilutions,  119 
dried,  in  scurvy,  361 
frozen,  effect  of,  109 
goat's,  in  idiosyncrasy,  186 
human,  content  of,  36 

in  athrepsia,  251 

in  enteral  infection,  299 

in  nutritional  disorders,  207 

percentage  of  iron  in,  412 
idiosyncrasy  as  factor  in  diar- 
rhea, 224 

toward,  186 
human,  82 

in  athrepsia,  duration  of  feed- 
ing, 257 
inspected,  109 
instruction  for  expression  of 

human,  58 
lime  water  in,  144 
magnesium  content,   14 
metabolism  of,  7 
mixed,  110 

underfeeding  in,  209 
necessity  of  clean,   106 
overfeeding,  with   insufficient 
carbohydrates,  200 


Milk,  pasteurizing  of,  433 

versus  boiling,  113 
percentage    method    of    feed- 
ing, 117 

precaution  with,  in  home,  107 
protein  content  of  cow's,  124 
proteins  of,  7 

requirement,  daily  total  of,  44 
salt  content  of,  132 
skim  and  cream  mixture,  155 
spoiled,     nutritional      distur- 
bance from,  195 
sugar  content  in,  105 
whole,  undiluted,  116 
Mixed  diets  for  young  infants, 

145 
Mixtures,  lactic  acid-corn  syrup, 

254 

Monosaccharides,  11 
Mouth,  physiology  of,  3 

Xitrogen    elements    in    protein, 

124 

metabolism,  9 
salts,   necessary   for  building 

body,  126 

Nursing,  axioms,  38 
contraindications  to,  37 
diet  of  mother  in,  38 
general  considerations  of,  35 
mother,  liquids  taken  by,  70 
regularity  in,  42 
successful,  signs  of,  61 
time  limit  for,  43 
total  period   for,  in  mothers, 

45 

wej:-,  46 

Nutritional     disturbances,     bad 
hygiene  as  cause  in,  196 
classification  of,  193 
constitutional   anomalies   as 

cause  of,  196 
differences  in,  278 
following  spoiled  milk,  195 
etiology  of,  190 


INDEX. 


493 


Nutritional    disturbances,    fac- 
tors in,  67 

following  underfeeding,  194 
from  overfeeding,  194 
general  classification  of,  198 
general     consideration     of, 

187 
improper  hygiene  as  cause 

in,  1% 

in  artificially  fed,  162 
increased    susceptibility    to 

infections  from,  277 
infections  in,  195 
with  diarrhea,  218 
without  diarrhea,  200 

Oatmeal  and  rice  water,  432 
Orange  juice,  441 

as  antiscorbutic,  365 
as  cure  for  scurvy,  382 
in  anemia,  422 
in  mixed  diet  for  young  in- 
fants, 145 
vitamines  in,  19 
when  to  begin  giving,  153 
Organs  of  body,  changes  of,  in 

rickets,  322 
Overfeeding,    crying   of   infant 

in,  78 

eczema  in,  75 
pyelitis,  result  from,  75 
pylorospasm  in,  75 
treatment  of,  76 
treatment  of  colic  from  78 
symptoms  of,  73 
washing  of  stomach  in,  78 

Pancreatic  ferments,  4 
Parathyroid     feeding,     without 

result  in  spasmophilia, 

357 

theory,  in  spasmophilia,  348 
Pasteurizing  of  milk,  433 
Phosphate,  excess  of,  factor  in 

spasmophilia,  349 


Phosphorus,  content  in  milk,  15 
excretion,  317 
preventive  of  rickets,  309 
metabolism  of,  in  normal  in- 
fants, 346 

Physiological  salt  solution  for 
removal  of  meconium. 
91 

Polysacchirides,  11 
Potassium,  content  of  milk,  14 
Powdered  milk  foods,  430 
Premature  infants,  methods  of 

feeding,  84 
Prematurity,  a  cause  of  debility. 

79 
as    factor   in   development   in 

rickets,  308 

Preparation  of  infant  food,  431 
Proprietary  foods,   as   deficient 

foods,  380 

Protein  requirements  for  in- 
fants, 126 

Proteins,  chemistry  of,  7 
content  of  blood,  in  normal  in- 
fant, 268 
daily  amount  used  by  adult, 

125 

digestion  in  infant,  152 
functions  of,  123 
metabolism  of,  8 
metabolism  in  products  of,  9 
in  cow's  milk,  ratio  of,  103 
in   development   of   intestinal 

organisms,  31 
in  stools,  24 
nitrogen  constituents  of,  124 

elements  in  protein,  124 
refraction  index,  in  anhydre- 

mia,  268 

requirement  in  feeding,  140 
result  of  excess,  203 
Prune  jelly,  442 

juice,  441 

Pudding,  cornstarch,  443 
custard,  443 


494 


INDEX. 


Pulmonary  ventilation,  in  acido- 
sis,  387 

Pulse  and  respiration,  average 
rate  of,  469 

Purgation,  castor  oil  in  for  new- 
born, 91 

Purpura,  377 

Pyelitis,  as  result  of  overfeed- 
ing, 75 

Pylorospasm  from  overfeeding, 
75 

Pylorus,  patency  of,  1 

Quartz  lamp,  use  of,  in  rickets, 
337 

Recipes,  430 

Record  sheets,  470 

Rectal  feeding,  457 

Reparative    stage    in   athrepsia, 
-251 

Rheumatic  fever,  as  suggesting 
scurvy,  377 

Rheumatism,  165 

Rickets,  304 

codliver  oil  in,  310,  339 
deformities  in,  328 
"    prevention  of,  340 
endocrine  gland  theory  in,  313 
etiology  of,  305 
fruit  juices  for,  333 
hygienic  treatment  of,  333 
main  varieties  of,  342 
medicinal,  treatment  of,  338 
mineral  metabolism  in,  313 
pathological  anatomy  of,  319 
pathology  of,  in  prematures, 

324 

prognosis  in,  330 
quartz  lamp,  exposures,  337 

prophylactic  agent  in,  336 
radio  diagnosis  in,  329 
relation  of  tetany  to,  342 
seasonal  occurrence  of,  307 
symptoms  of,  325 


Rickets,  treatment  of,  331 
ultra-violet  rays  in,  333 
Ringer's   solution,   administered 
by    rectum    in    prema- 
tures, 91 

in  anhydremia,  271 
Rumination,  165 

Saline  solutions,  459 
intravenously,  460 
subcutaneously,  459 
technic,  460 
Salts,  chemistry  of,  14 
content  in  milk,  132 
excretion  of,  16,  24 
function  of,  15 

in  cow's  milk,  factor  in  nu- 
tritional disturbances, 
105 

necessary  in  nitrogen  reten- 
tion, 126 

relation  of,  to  metabolism,  15 
Scurvy,  358 

diagnosis  of,  376 

dietetic  treatment  of,  381 

differentiation      from      acute 

nephritis,  378 
from  osteomyelitis,  378 
from  poliomyelitis,  378 
etiology  of,  358 
infections  related  to,  362 
pathological  anatomy  in,  367 
prognosis  of,  379 
proprietary  foods,  as  factors 

in,  360 

radiological  diagnosis  of,  375 
resemblance  to  beriberi,  364 

to  pellagra,  364 
response  in,  to  vitamines,  215 
symptoms  of,  373 
treatment  of,  379 
Sleep,  467 
Spasmophilia,  341 
active  manifestations  in,  341, 
353 


INDEX. 


495 


Spasmophilia,  calcium  salt  dim- 
inution, as  factor  in, 
349 

diet  in,  355 
latent  signs  in,  350 
medical  treatment  in,  356 
parathyroid  theory  in,  348 
phosphate  excess,  as  factor  in, 

349 

prognosis  in,  355 
seasonal  occurrence  of,  344 
symptoms  of,  349 
treatment,  355 
Sodium,  content  in  milk,  14 
Soups,  438 
Startoline,  435 
Starvation,  as  factor  in  aciclo- 

sis,  393 

'Sterilization  of  milk,  433 
Stomach,  capacity  of,  2 
secretions  of,  3 
position  of,  1 
washing,  455 
Stools,  abnormal,  177 
carbohydrate,  185 
characteristics  of,  in  anhydre- 

mia,  263 

in  athrepsia,  247 
in  flour  excess,  227 
in  infections,  290 
characteristic  types  of,  180 
color  of,   178 

foamy,   in  carbohydrate   fer- 
mentation, 227 

formation,  effect  of  fat  on,  24 
hunger,  characteristics  of,  25, 

69 
in  diarrhea,  characteristics  of, 

226 

in  flour  injuries,  213 
in    underfed,     characteristics 

of,  233 

normal,  characteristics  of,  25 
of  breast-fed  babies,  61 
soap,  183,  202 


Stools,  associated  with  consti- 
pation, 205 
tests  in,  178 

Sugar  content  in  milk,  105 

Sugars  and  starches,  as  cause 
of  nitrogen  retention, 
126 

Sunlight,  as  preventive  of 
rickets,  307 

Syphilis,  377 

Tannigin,  in  diarrhea,  236 
Tea,      administration      of,      in 

athrepsia,  255 
recipe  for  making,  431 
Technic    of    intravenous    injec- 
tion, 460 
Teeth,  number  of,  at  time,  61 

eruption  of,  468 
Test,   Marriott's,  colorimetric, 

398 

for  constituents  of  feces,  24 
Sellard's,   in  acidosis,  394 
Van  Slyke's,  in  acidosis,  399 
Tetany,     predisposition     to,     in 

prematures,  343 
relation  to  rickets,  342 
Tomatoes  as  antiscorbutic,  366 
Trousseau's  sign.  353 

Underfeeding,     as      factor     in 

rickets,  308 
Urea,  in  urine,  9 
Uremia,  presence  of,  in  anhy- 

dremia,  261 
Urine,   ammonia   in,  neutralied 

by  acids,  389 

ammoniacal    in    disturbances 
without  diarrhea,  205 
average  daily  quantity,  469 
characteristics  of,  in  scurvy, 

374 
examinations,    period    to    be 

covered  by,  6 
fats  in,  10 
in  anhydremia,  264 


496 


INDEX. 


Van  Slyke's  test,  in  acidosis,  399 
Vegetables,  446 

for  infants,  145 
Vitamines,  18 
classification  of,  364 
deficiency       in       lactating 
mothers,    as    factor    in 
rickets,  306 
improvement  from,  in  athrep- 

sia,  255 

lack  of,  in  flour  injury,  212 
lack,  no  relation  to  spasmop- 

hilia,  344 
relation  to  deficiency  diseases, 

362 
result   from,  in  malnutrition, 

215 

specifics  of,  367 
Volatile  acids,  in  milk,  105 
Vomiting,  162 

from  overfeeding,  74 

in  anhydremia,  263 

in  infection,  284 

in  overfed,  washing  stomach 

for,  78 

treatment  of,  166 
Von  Jaksch's  anemia,  415 

Water,  albumin,  432 

administration      in      acidosis, 

401 
in  athrepsia,  250 


Water,  amount  administered  to 
prematures   in  twenty- 
four  hours,  91 
injection  in  peritoneal  cavity, 

technic  of,  272 
lack  of,  dangerous,  134 
to  be  added  to  feedings,  142 
requirement  of,  44 
metabolism  of,  16 
Weaning,  care  of  breasts  dur- 
ing, 66 

indications  for,  65 
Weight,  affect  of  carbohydrates 

on,  13 

an  estimate  of  progress,  121 
average,  466 

daily  gains,  in  prematures,  96 
fluctuation  in,  cause  of,  241 
gain  for  nursing  infants,  61 
loss  in  anhydremia,  263 
in  athrepsia,  238 
in  infections,  290 
Wet-nurse,  diet  of,  53 
garments  for,  53 
hygiene  of,  52 
requirements  of,  47 
work  of,   54 
Whey,  434 

White  cell  count,  average,  469 
line  of  Fraenkel,  376 
of    egg    and    digested    gruel, 
432 


Date  Due 


PRINTED    IN    U.S.A.  CAT.      NO.      24       161 


/.£ 


UC  SOUTHERN  REGONAL  UBRARYf  AOUTV.. 


A    000416974    4 


CO 

UJ 
CD 


V7S120 
H586p 

1922 

Hess,   Julius  H 

Principles   and  practice  of 
infant   feeding. 


WS120 
H536p 


less,  Julius  H 

Principles  and  practice  of  infait 
feeding  . 


MEDICAL  SCIENCES  LIBRARY 

UNIVERSITY  OF  CALIFORNIA,  IRVINE 

IRVINE,  CALIFORNIA  92664 


